Risk Management Tools & Resources


CASE STUDY: Hasty Prescribing of Pain Medication Leads to Patient Overdose

CASE STUDY: Hasty Prescribing of Pain Medication Leads to Patient Overdose

Case Details

The patient was a male in his mid-forties who suffered from chronic pain of unknown etiology. He was a long-time patient of Dr. B, a MedPro-insured family practice physician. Dr. B referred the patient to an anesthesiologist, Dr. M, who subspecialized in pain management.* Dr. M started the patient on a fentanyl patch (25 mcg/hour), and then gradually increased the patient’s dose to 100 mcg/hour.

After not being evaluated or treated by Dr. B for some time, the patient called the family physician’s office and requested a refill for his fentanyl patch. He stated that he was leaving town and was unable to get in touch with Dr. M to secure the refill. Dr. B’s medical assistant prepared the prescription, and Dr. B signed it.

Within 48 hours of receiving the refill, the patient was found dead. The cause of death was drug overdose from fentanyl, possibly suicide. The patient’s family filed a lawsuit against Dr. B and Dr. M alleging improper management of the patient’s medication regimen.

* Dr. M was not insured by MedPro; thus, the risk management discussion below focuses on the care and treatment provided by Dr. B.


Two major risk management issues identified in this case are poor clinical judgment and inadequate communication. The term “clinical judgment” refers to decisions made in relation to information gathered from the patient, observation, and a healthcare provider’s own personal experience, knowledge, practice, and critical thinking skills.

In this case, Dr. B provided a refill for the patient’s fentanyl patch without physically evaluating the patient or even speaking to him on the phone. Because the patient had not been seen or treated by Dr. B for some time, and because of the nature of his request, an updated history and physical were warranted.

Additionally, because Dr. B had not prescribed fentanyl to the patient previously, he had never provided the patient with information and education about the risks of the medication. Dr. B likely assumed that the patient had already received such information because the request was a refill of Dr. M’s prescription. However, because of the liability associated with opioids and pain management, Dr. B would have been prudent to provide the patient with information about the risks of his medication and to document these educational efforts.

Dr. B also failed to communicate with Dr. M or someone in his office regarding the patient’s request. Doctor shopping is a common practice for patients who have prescription drug addictions, and the circumstances of this case should have been a potential red flag for drug-seeking behavior. A call to Dr. M’s office to determine whether the patient was really in need of a refill might have prevented Dr. B from authorizing the fentanyl prescription.

In Summary

Patients who suffer from chronic pain and use opioids as part of a pain management regimen can present challenges for healthcare providers. Even a request as simple as a refill can have serious consequences, as this case study illustrates. To address risks associated with high-alert medications, healthcare providers should develop and follow thorough policies for prescribing.

Prescribing policies should (a) clearly establish which staff members in the practice are authorized to prescribe controlled substances, (b) define protocols for handling requests for new prescriptions and refills, (c) set clear parameters for when prescribing in the absence of a medical evaluation is prohibited, and (d) establish requirements for checking prescription drug monitoring programs.

In addition to prescribing policies, healthcare providers should assess their communication protocols to determine whether they are collaborating effectively with other providers who are involved in patients’ care, having thorough informed consent discussions with patients, and providing adequate and appropriate patient education.

MedPro Twitter


View more on Twitter