Who Is At Fault: The Provider
The provider is primarily at fault for failing to obtain a complete medication and travel history before prescribing digoxin to a patient from a malaria-endemic area. This represents a fundamental breach of the standard of care in prescribing cardiovascular medications, particularly those with narrow therapeutic indices and significant drug interaction potential.
Why the Provider Bears Primary Responsibility
Duty to Obtain Complete History
The provider has the primary duty to obtain a complete medication history before prescribing any drug, especially digoxin, which has numerous drug interactions and requires careful patient assessment 1.
Multiple cardiovascular guidelines emphasize that digoxin should be used cautiously in patients taking other drugs that can affect digoxin levels, and the prescriber must be aware of all concurrent medications 1.
The provider's failure to ask about travel history is particularly problematic because antimalarial medications (such as chloroquine, hydroxychloroquine, and quinine) can significantly increase digoxin levels and precipitate toxicity 1, 2, 3.
Specific Prescribing Requirements for Digoxin
Before initiating digoxin, the provider must assess multiple factors including renal function, age, lean body mass, electrolyte status, and concurrent medications 1.
Digoxin toxicity can occur even at therapeutic levels when hypokalemia, hypomagnesemia, or drug interactions are present, making the initial assessment critical 1, 2, 3.
The provider should have verified that the patient had no contraindications such as significant sinus or atrioventricular block before ordering digoxin 1.
Why Other Options Are Not Primarily At Fault
The Patient (Option D)
While patients should ideally bring medication lists, the legal and ethical responsibility for obtaining a complete history rests with the prescribing provider, not the patient 1.
Many elderly patients with cardiovascular disease take multiple medications (polypharmacy affects 30-50% of older adults), and it is unrealistic to expect all patients to spontaneously report every medication without being asked 1.
Patients from endemic areas may not recognize that antimalarial medications are relevant to cardiac care unless specifically questioned 1.
The Pharmacist (Option C)
While pharmacists provide an important safety check, they cannot be expected to know the patient's travel history or undocumented medications that the provider failed to elicit 1.
The pharmacist's role is to verify appropriateness based on available information, but if the provider's order appears reasonable on its face and the patient's antimalarial use is undocumented, the pharmacist cannot catch this error 1.
The Nurse (Option B)
Nurses implement orders but are not primarily responsible for the prescribing decision or the initial medication history 1.
While nurses may catch errors, the fundamental failure occurred at the prescribing stage when the provider did not obtain adequate history 1.
Computerized Systems (Option A)
- Electronic prescribing systems can only alert based on documented medications; they cannot identify undocumented drugs the provider failed to ask about 1.
Critical Clinical Pitfalls to Avoid
Essential Pre-Prescribing Assessment
Always obtain a complete medication history including over-the-counter drugs, herbal products, and supplements before prescribing digoxin, as more than 60% of cardiovascular patients use complementary medications that may interact 1.
Specifically ask about recent travel to malaria-endemic areas and any antimalarial prophylaxis or treatment 2, 3.
Verify renal function (creatinine clearance), electrolytes (particularly potassium and magnesium), and thyroid function before initiating digoxin 1, 2, 3.
High-Risk Drug Interactions
Medications that increase digoxin levels include amiodarone, clarithromycin, erythromycin, itraconazole, cyclosporine, verapamil, quinidine, propafenone, and dronedarone 1, 2, 3.
Antimalarial drugs (chloroquine, hydroxychloroquine, quinine) can significantly elevate digoxin levels and must be identified before prescribing 2, 3.
Documentation Requirements
Document the specific questions asked about medication history, travel history, and the patient's responses 1.
This documentation protects against liability and ensures continuity of care 1.
Medicolegal Considerations
The standard of care requires providers to obtain a complete history before prescribing medications with narrow therapeutic indices like digoxin 1.
Failure to obtain this history constitutes negligence if harm results, as the adverse outcome was foreseeable and preventable 1, 2, 3.
The provider cannot delegate this responsibility to the patient, nurse, pharmacist, or computer system 1.