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

Sara,

I posted your question/desire for feedback on our Facebook page and two NPs posted the following:

"I am always cautious with complex medication use and decision making without back-up of my own experience or consult with another provider. I may tell the person I am going to consult and will get back with them after the visit. A benefit of office practice is that you have time for decision making as it is not an emergency."

"I'm not sure I would consider this a medication error since the patient responded positively to the medication. Ok, a higher dose might be more effective. You didn't prescribe something that from left field, it was a very appropriate medication. Don't be too hard on yourself. I made an error the first time I used the electronic system instead of writing pad. I almost had a panic attack but the patient was not harmed and that's the top priority for me." 

 Thank you for your participation in our discussion board.

Michelle Pronsati, editor 

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Michelle Perron Pronsati

I'm EdDNP.DCC.PAC. We all make mistakes. It is importatnt to learn from them. I have bee in practice for 17 years. This is not an easy job. Look up medications and treatments in the Washington Manual and the Harrison Internal Medicine books.

I am a new NP myself. I have been in practice for just over a year. While I was finishing my clinicals, a very kind MD who worked with the NP precepting me gave me words of encouragement, and I think the best were "Know that you'll make mistakes, forgive yourself and learn from your mistakes..."