Clinical Scenario   This patient was seen at her primary physician’s office for episodes of blepharitis.  The patient was referred to an ophthalmologist who diagnosed her with keratitis.  She was prescribed short-term steroids. Subsequently, the patient returned to the primary physician’s office complaining of redness and crusting of her left eye, at which time she was diagnosed with left conjunctivitis and prescribed eye drops. The patient continued to see the ophthalmologist for several follow-up visits for her blepharitis. During these visits, the ophthalmologist changed the prescription to prednisolone eye drops. Intraocular pressure was measured during this time.    The patient then returned to her primary physician who noted continued blepharitis and keratitis. At the urging of the patient, for economic and convenience reasons, the primary physician wrote a prescription for prednisolone eye drops. From this point forward, the primary physician assumed responsibility for prescribing the prednisolone eye drops and continued to authorize refills for the medication for the following five years. During one interval, 12 refills were approved by the primary physician and filled by the local pharmacy. The medication was refilled without requirement to be evaluated in the office prior to authorization or referral back to the ophthalmologist for intraocular pressure measurement.   Following years of steroid treatment, the patient returned to the ophthalmologist due to vision disturbances. The patient was diagnosed with steroid-induced glaucoma and was subsequently followed by the ophthalmologist, who also determined that the patient has a cataract and loss of peripheral vision in the left eye. While a corrective lens has improved vision in the right eye, over time, the condition will worsen and require cornea surgery.   Allegation & Outcome   The patient brought suit against her primary physician for prescribing steroid eye drops over a prolonged period of time, resulting in steroid-induced glaucoma and vision loss. The claim was settled prior to trial.   Clinical Perspective   Given the potential side effects of the medication and the admission by the primary physician to lack of expertise in ophthalmology, continued care of the patient should have been coordinated with the ophthalmologist for medication management and monitoring.   The patient was not informed that the long-term use of a steroid such as prednisolone carried a risk for developing glaucoma and impaired visual acuity and/or cataract.     Defense Perspective   The physician/defendant conceded that there was no consideration given to the need for monitoring while prescribing the medication.   The glaucoma was uveitic in nature, a result of the underlying ocular condition. However, all experts agreed the patient also experienced steroid-induced glaucoma.   The pharmacist/co-defendant played a role in failing to question the repeated prescription refills. The pharmacist also failed to provide the patient with medication counseling in accordance with New Jersey statutes.   Patient Safety & Risk Management Perspective   Clinicians should be cognizant of their own scope of practice. Accommodating patient requests at the cost of good medical judgment may impair clinical outcomes.   Direct communication with specialists to coordinate care is essential.   Patients must be informed of potential serious side effects associated with certain medications. Documentation should reflect the discussion with the patient, including the risks, and that the patient expressed understanding and agreement.   All clinical staff and physicians should be aware that certain medications, such as ophthalmic steroids, require routine testing to prevent serious side effects.   All clinical staff and physicians must comply with New Jersey laws and regulations pertaining to prescriptions, particularly refills.     For information on safe medication practices, go to this article from our September 2008 issue at: http://www.princetoninsurance.com/downloads/ Risk_Review_Downloads/9.2008/09.2008_RM_Med.management.pdf