Safety of care
Informal telephone advice
Originally published Spring 1996 / Revised January 2011
When providing advice informally to others or over the telephone, obtain sufficient information on which to base your professional opinion, as they may rely on the advice.
This article was based on a case which occurred several years ago. The practice of medicine continues to evolve and the medications named, the dosages, methods of administration and other aspects of medical treatment or surgical intervention may have changed. Nevertheless, the CMPA believes the patient safety issues and medico-legal principles demonstrated are still relevant.
The telephone is an indispensable part of medical practice, and is often used to communicate with patients. It is easy to become blasé about its use.
The following vignette from our files demonstrates a doctor's vulnerability in "informal" consultations that can develop through telephone contact.
A young woman of 33, mother of 1 child, had been depressed and had been prescribed imipramine, a tricyclic antidepressant. The family had left the community where she had received the prescription and traveled a considerable distance to her parents' house. Her husband returned to the parent's house one afternoon to find her very drowsy. He realized that she had taken some of her anti-depressant tablets. He phoned the local hospital and a nurse took the call.
The nurse reports that she was asked whether six 50 mg tablets would be an overdose. The emergentologist was close by the phone, saw the nurse searching in a drug reference text, and volunteered that 300 mg would be a high therapeutic dose and there should not be any ill effects. The husband believes he went on to report that his wife had experienced hallucinations and was comatose, but he then discontinued the call without leaving a return telephone number or his name. The nurse on questioning said that she felt she could rely on the doctor's statement and no further questioning was needed.
Unfortunately the woman died. After her death it became clear that she had taken some 90 tablets, not just six. The patient's husband and young daughter sued the hospital, the nurse, and the doctor. At trial the doctor had to agree that 300 mg would not be an appropriate dose for a young child or an elderly person. The plaintiff's lawyer said this demonstrated the fact that the doctor had offered an opinion without obtaining sufficient information about the case. The judge found that the death of the woman arose out of negligence, with the husband having 70% responsibility and the nurse and doctor each 15%.
The whole interchange with the nurse, husband, and doctor would have taken less than 5 minutes but resulted in scrutiny of the care provided for the next six years. Each party had to try to remember that exchange verbatim and of course there were differences in recollection. No notes had been made by the doctor or the nurse. Even more importantly, while notes would have been of assistance, a different outcome might have been expected if a full history had been taken from the caller. This unfortunate case illustrates the danger that lurks in the casual provision of advice.