Not long ago, a doctor friend recounted the story of a patient who had recently died from complications stemming from the treatment of a chronic bleeding problem. “I felt terrible about it,” said my friend, who had cared for the patient for several years. “Something didn’t add up in this case, and I had to wonder if it was my fault, if I had done something wrong.”
Spurred on by these recurrent self-doubts, my friend went back to review the records. Nothing at first glance seemed amiss; all the recommendations, visits and discussions were consistent with what both of us knew was good, evidence-based clinical care.
But then, while reading through the pharmacy records, my friend discovered something unexpected. The patient, it turned out, hadn’t been taking all of the medications my friend had prescribed. In fact, several of the prescriptions had never even been filled.