New NP needing encouragement

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    So I recently found out that I made a mistake prescribing a patient medication. (I'm in primary care and addiction medicine in a community health clinic). This patient had been previously diagnosed by rheumatology as having possible RA vs scleroderma but had not followed up with them in over 2 years and had been on plaquenil all that time. She came in complaining of severe bilateral joint pain in her shoulders which were extremely tender to touch with limited ROM. I tried to call rheumatology but was unable to reach anyone for consult, so decided to start the patient on methotrexate with leucovorin and get her in to see the rheumatologist ASAP. However, though I sent the referral, it took them 3 months to actually see her. I was monitoring her CBC and CMP as required while on methotrexate therapy and she seemed to be responding well and her labs were all normal. I had realized somewhat late that typically methotrexate is prescribed by a rheumatologist and not a PCP, but she seemed to be doing well so I figured I might as well continue.
    Well, the rheumatologist recently emailed me after the patient missed her appointment and we discussed the current treatment. She told me that while she could tell I was trying to help the patient, this was NOT appropriate, the dose was too low and the leucovorin would counteract the effects of the methotrexate anyway (Epocrates led me astray: said it should be prescribed with the methotrexate but I guess it's better to do folic acid 1mg).
    Although the patient wasn't hurt, I feel really bad about it, and I just need to hear some mistakes other people have made in their careers and what the process was like of getting through the beginner phase.
    Thanks
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  3. 6 Comments so far...

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    Everyone makes mistakes. Live and learn. In the end I think you learned a valuable lesson without having any harm come to anyone: don't prescribe a medicine you are not comfortable prescribing.
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    Agree with above. My med error involved a similar situation: I'm in nephrology but prescribed a med that a PCP would give.

    ePocrates (and all references for that matter) are fallible.

    Lesson learned - I always, always, always check two references and I use UpToDate as well as a lit search - ePocrates is out of my vocabulary!

    Another thing that has helped me tremendously: I have my own little formulary and rarely vary from it. If I have to start a drug that I'm not familiar with - I do my research and then double check it.
    SHGR likes this.
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    Ditto. If just the name of a drug raises the short hairs on my neck - I seek out another opinion. We all do alot of busy PT care and occasionally get wrapped up in something we'd rather not be a part of. Chalk it up to experience and press on.

    I recently had a PT that wanted me to manage all of her anti-HTNs Rxs. No prob, except she is followed by cardiology who does stuff like off label use of meds. I make a living managing HTN, but I can't make any informed decisions if a cowboy cardio is going to experiment. Normally, I'd do anything for the lady, but I had to apologize and send her back to the cardiologist.
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    Yes that is true also CRF250xpt - I manage HTN for my dialysis its except in the case of cards doing so.
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    Quote from CRF250Xpert

    I recently had a PT that wanted me to manage all of her anti-HTNs Rxs. No prob, except she is followed by cardiology who does stuff like off label use of meds. I make a living managing HTN, but I can't make any informed decisions if a cowboy cardio is going to experiment. Normally, I'd do anything for the lady, but I had to apologize and send her back to the cardiologist.
    I agree, you should defer to the cardiologist especially if he/she is the one who started the med.

    I think calling someone who is an expert in the field a cowboy when they do off-label stuff may not be completely right. Now I don't know what he/she was doing (and it may have been outright wrong) but in more than a few circumstances, the label just isn't right. For instance, nifedipine XL is a labeled as a once daily med with a supposed max of 120 daily. For refractory hypertension it is given BID (especially in renal patients) and frequently 120mg BID (so double the supposed max daily dose). Lisinopril by label is again once daily and rarely given with an ARB since they end in the same common pathway. However, in patients with a highly active Renin-angiotensin-aldo axes it is often given BID or with an ARB. So, I guess what I am saying is perhaps he/she had a reason since he/she is the expert in the field.
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    I will say that my renal pts need a lot of meds to get their BP to anything close to acceptable.

    Sometimes its all in why you are prescribing it.


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