Pholcodine reaction - medical case study

Mr A attended his GP with a persistent cough and was diagnosed with an upper respiratory tract infection. Dr Z subsequently prescribed pholcodine linctus to treat the cough. Unfortunately, the doctor failed to note that he had an allergy to codeine and opiates. The patient suffered a severe reaction to the medication that required several days of hospital treatment, including time in intensive care. The patient eventually made a full recovery.

A complaint was made about the doctor on the basis that Mr A’s allergy was documented in his medical records. During her consultation with Mr A, Dr Z explained that an initial computer alert about the allergy wasn’t noted and no further alert was raised by the system when she later decided to prescribe the drug. Dr Z subsequently tested the practice computer and said there was a fault in the prescribing system that should have stopped her from completing a pholcodine prescription for Mr A. Dr Z was certain she would not have prescribed the opiate if the appropriate alerts had been built into the computer system.

Analysis and outcome

MDDUS sought an expert report on the case. He found that the computer system was not designed to identify pholcodine as part of the codeine drug group. It was agreed with the software company that future alerts for codeine drugs would include pholcodine. However, he found that Mr A’s paper and computer records both clearly documented his allergy to codeine and opiates and there was no evidence of a systems failure in the practice. In prescribing pholcodine to a patient with a clearly documented allergy, he said Dr Z’s care fell below an acceptable level. MDDUS ultimately decided the case could not be defended and agreed a modest settlement on behalf of Dr Z.

Key points

• Always be aware of possible drug allergies when prescribing medication.
• Do not rely solely on automated systems to alert potential contraindications in prescribed drugs.