Safety of care

Improving patient safety and reducing risks

Collaborative care and medication monitoring: Who's responsible?

An article for physicians by physicians
Originally published June 2003 / Revised April 2008


Monitoring medications in shared care.

Of interest to physicians transferring or receiving patients

Case 1

An elderly woman was transferred from a chronic care facility to a rehabilitation centre. A list of the medications she had been taking was compiled by a nursing assistant at the original facility and copied onto the new doctor's orders by a nursing assistant at the rehabilitation centre. The physician confirmed by phone that the medications were to be continued.

The patient had been receiving methotrexate once a week, but the original list wasn't clear and the orders were copied incorrectly for methotrexate once a day. The patient developed problems. A consulting physician examined her and recommended transfer to an acute care hospital under his care. The list of medications from the rehabilitation centre was also transferred, copied onto new orders and signed by the consultant. The next day the hospital pharmacist discovered the error while dispensing the prescription. The methotrexate was stopped temporarily. The patient recovered.

The legal action that ensued had to be settled on behalf of all the physicians and the rehabilitation centre. It is common practice to copy medications onto new orders that are signed by the admitting physician. However, physicians should be aware that once care is assumed, it is their responsibility to scrutinize the treatment.

Case 2

An elderly man arrived at hospital with a urinary tract infection. The ED physician diagnosed septicemia. A urologist was consulted and agreed to assume care. The ED physician admitted the patient and wrote the orders in consultation with the urologist. The patient, who was already on lithium, was started on intravenous gentamicin. The orders called for lithium levels but not gentamicin levels.

The patient received gentamicin for three days. His condition stabilized and he was discharged. Home care nurses were given instructions for intravenous gentamicin twice a day. Blood levels of gentamicin were not ordered. The urologist relied on the home care nurses to inform him of any concern, but the discharge nurse's instructions to the home care nurses did not reflect this.

The patient developed dizziness and difficulty walking and reported these symptoms to the home care nurses. The urologist was not informed. The patient was seen in emergency, but the ED physician was not advised that the patient had been receiving gentamicin at home. By the time the urologist was informed, the patient had vestibular damage with permanent sequelae.

The legal action later advanced against the urologist, the ED physician and the hospital had to be settled. No expert support could be found for not ordering gentamicin levels. The experts also commented on the monitoring deficiencies, in particular that the signs of renal failure and ototoxicity were not observed.

In both these cases, several health care professionals were involved in managing the patients' medications.

Physicians should be satisfied that appropriate steps are taken to monitor medications:

  • review orders before signing them;
  • consider whether medications need to be continued for patients who are being transferred;
  • when in doubt, talk to the previous treating physicians and/or obtain copies of the records;
  • consider what is the appropriate frequency and detail of monitoring for patients receiving a drug with potential toxic effects, and whether blood level tests should be ordered; and
  • on discharge, provide and document clear care and follow-up instructions to patients and home care providers, including signs and symptoms to watch for and actions to be taken.


DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.