Who is at fault when a patient from a malaria-endemic area, admitted with heart failure, is prescribed digoxin without the provider inquiring about their travel or medication history?

The Provider is Primarily at Fault

The provider who failed to obtain a complete medication and travel history before prescribing digoxin bears primary responsibility for this error, as obtaining an accurate medication history is a fundamental standard of care that directly prevents foreseeable harm from drug interactions. 1, 2

Why the Provider is at Fault

Failure to Meet Standard of Care

• The American Medical Association explicitly states that obtaining a complete history before prescribing medications with narrow therapeutic indices like digoxin constitutes the standard of care 2
• The European Society of Cardiology emphasizes that failure to obtain this history constitutes negligence if harm results, as the adverse outcome was foreseeable and preventable 2
• Antimalarial drugs (chloroquine, hydroxychloroquine, quinine) can significantly elevate digoxin levels and must be identified before prescribing 2

Specific Breaches in This Case

• The provider failed to ask about travel history to malaria-endemic areas, which should trigger inquiry about antimalarial prophylaxis or treatment 2
• The provider failed to obtain a complete medication history including over-the-counter drugs, herbal products, and supplements before prescribing digoxin 2
• 67% of medication histories have at least one prescription error, 22% of which have the potential to harm the patient significantly - making this a known, preventable hazard 1

Why Other Parties Have Lesser Responsibility

The Patient (Option D)

• While patients should ideally bring medication lists, the legal and professional responsibility to obtain an accurate history rests with the prescriber, not the patient 1, 2
• Patients from endemic areas may not recognize the relevance of antimalarial medications to their current cardiac treatment 1
• The provider cannot delegate their duty to obtain a complete history to the patient 2

The Nurse (Option B)

• Nurses have a duty to clarify unclear orders and question potentially dangerous prescriptions, but the primary error occurred at the prescribing stage 1
• The nurse's failure to write drug formularies is a documentation issue, not the root cause of the prescribing error 1

The Pharmacist (Option C)

• Pharmacists obtain better medication histories than physicians and reduce medication errors during acute admissions 1
• However, pharmacists cannot check for drug interactions if the patient's antimalarial medication history was never documented in the system 1
• The pharmacist's role is a safety net, not a substitute for proper prescribing practices 1

The Computerized System (Option A)

• Computerized systems can only detect interactions if all medications are entered into the system 1
• If the provider never documented the antimalarial medication because they never asked about it, the system cannot flag the interaction 1

Critical Clinical Context

Digoxin-Antimalarial Interactions

• Antimalarial drugs (particularly chloroquine, hydroxychloroquine, and quinine) significantly increase digoxin levels through P-glycoprotein inhibition 2, 3
• This interaction can cause life-threatening digoxin toxicity even at therapeutic doses 3
• Extreme caution and close clinical monitoring is required when quinine is used to treat persons with malaria who have been taking mefloquine prophylaxis, because quinine and mefloquine are similar regarding their pharmacology and cardiovascular and neurological toxicity 1

Hazardous Settings and Patients

• Elderly patients constitute a readily identifiable high-risk group for medication errors 1
• Patients with heart failure often take multiple medications, increasing interaction risks 1
• Inaccurate histories, particularly on admission to hospital, can lead to prescribing errors, such as duplication of drugs or unintended discontinuation of medications, with consequent unwanted interactions 1

Medicolegal Bottom Line

The provider's failure to obtain a travel and medication history before prescribing digoxin represents a clear breach of the standard of care. While a systems approach to medication safety involves multiple checkpoints (pharmacist review, nursing verification, computerized alerts), the primary responsibility for safe prescribing rests with the prescriber who writes the order. 1, 2