What To Do When Patients Press Record in the Emergency Department

What To Do When Patients Press Record in the Emergency Department

Dear Director: It seems like more and more patients are trying to record me during my encounter with them. Sometimes it’s in the history portion, sometimes they want to record the procedure. I don’t want to end up going viral or get sued. Can I say no?

How many times have you seen friends post a picture of themselves or their family in an ER hospital bed? Technology has changed over the last decade, putting a high quality camera and recorder in everyone’s pocket, while social media has made it “normal” for people to post personal and private matters online. Thus, more of us are being confronted with a camera in our face as we perform our job in the emergency department. I was at a surgeon’s office last week, and there was a big sign at their registration window that said, “Absolutely no pictures or video recording.” I was afraid to even take a picture of the sign for fear that they would kick me out of the office, and I wouldn’t get the care that I need. There is no doubt we need to develop a policy that is in line with modern technology and social behavior.

Background
For decades, hospitals have been dealing with anxious parents as they want to record the birth of their child in labor and delivery. Interestingly, there are actually no national standards for allowing or not allowing recording equipment in the hospital, so each hospital must develop their own policy. And while patients or their families may say it’s their right to record themselves, that’s only true if they’re on their own property. Once they are on hospital property, patients and visitors must comply with hospital rules.

Motivation to Record
While I didn’t do this for my own kids, it does kind of make sense to me that people would want to make recordings in L&D. The motivation there is generally not to capture an error but rather to record a life-changing family event.

However, just like the family member who starts noting your time of arrival into a room and exactly how to spell your name before you even ask why the patient is there, you have to question why someone might want to record parts of their ED encounter. In this case, it’s likely that the family wants to document something because they assume something went wrong or will go wrong, or they’re already unhappy. My hospital rarely gets complaints about our video policy outside of L&D, so if someone wants to record something in the ED, your radar should be up. While a before and after picture of a laceration doesn’t bother me, it would be very bothersome to have a camera in my face while I’m actually doing my procedure. However, there can be some potential advantages of recording. Some physicians are encouraging patients to record the conversation about discharge instructions so that they can re-watch them if there are questions.

What’s There To Be Afraid Of?
The theory goes that if you’re doing everything right and practicing within the standard of care, there’s really no reason to fear a recording. But a camera and a recording can change everything. Although we work in a fishbowl and are used to “performing” at times for patients, most of us aren’t actors and we all should be focused on the patient and not focused on how we look, act, or speak on camera. Most of us come to work to take care of patients, not for the potential to be an Internet star. Probably most of us heard about the case where a patient turned on his phone recorder prior to a colonoscopy (with the intent of hearing discharge instructions), and then the anesthesiologist made insulting remarks about the patient. The procedure took place in 2013, and the malpractice case concluded in 2015. Clearly the doc wasn’t “doing everything right” and wasn’t professional, but the recording cost them in court and made them infamous.

Someone making a recording can also get in the way of caring for a patient. In areas of the hospital where a patient can worsen quickly and without notice (L&D and the ED), all eyes should be on protecting and caring for the patient – not on dealing with someone who may be in the way by making a recording.

Hospitals also have an obligation to protect the privacy of their patients (remember HIPAA?). Someone may be making a recording of their family member but then capture another patient in the process who does not want to be recorded and didn’t give consent. While TV news crews can film the outside of a hospital (with the normal people coming and going) from the sidewalk (considered public grounds), you typically won’t see news cameras inside the hospital without someone from your PR office carefully controlling the image and what’s visible so the rights of patient’s privacy are protected.

Physicians and hospital administrators are also concerned about how video may be used. It’s one thing to show a friend how goofy your teenager is after receiving meds from surgery; it’s another if it could be used for litigation. It’s so easy to edit recordings now that a chopped up sequence of events would not show the entirety of the situation and may not be a fair reflection of what happened. Thus, the recording could lose the true perspective of events.

Putting Aside Distraction
I filmed a commercial for a hospital years ago. I’ve had no acting experience since the sixth grade, but the script was simple, I had a teleprompter, and the director thought the whole thing would take a matter of minutes to film. An hour later, I was embarrassed to still be there (on some takes there were issues of the lights reflecting off my bald head and on other takes, I missed my mark when I was walking in) and ready to get back to the ED, but the director thought he finally had a good take. I never thought acting was easy, but this experience proved it to me. It also serves as a reminder about how as clinicians we need to focus on our jobs while not being distracted. Whether it’s a camera in your face or the perceived threat of a lawsuit, these are distractions that could interfere with patient care.

Next Steps
The hospital has an obligation to protect the facility, staff, physicians, and patients and doesn’t want to compromise any party. As with many administrative questions, the answer may lie in your hospital’s policy book. Get to know your policy on patients making recordings and make sure your policy is consistent with your work environment and concerns. While the policy may prohibit recording in L&D, it may not comment on the rest of the hospital or it may only prohibit it in L&D during the actual birth. If it doesn’t include the ED, now’s the time to work with your public relations department to come up with a set of rules that are applicable to the ED.

I would propose absolutely no recordings and no photographs that include staff or other people/patients in the ED. Unless it’s a big problem, I wouldn’t advocate putting signs at triage or in patient’s rooms. While I’m not likely to tell a patient not to take a selfie in the ED, I will ask them not to do it while I’m at the bedside. If a patient wants to record something it’s always helpful to be able to say that our hospital prohibits the use of recording devices. If you don’t have a policy, or if they argue with you, I suggest politely saying that this conversation is taking attention away from the patient and not helping the patient and that you don’t consent to being recorded. While I would never advocate walking away from a sick patient, if you have the luxury of time, I would step out of the room. If the family is recording because they’re afraid of a mistake or if there’s a grievance, you can have someone from patient relations come talk to them.

When All Else Fails
It may, on rare occasions, be necessary to call security. If someone continues to record in the ED against hospital policy, you have to remove them. While there are clear needs for hospital security when it comes to a violent patient, I think of calling security as a last resort in this situation, as it may further irritate a patient or family member in what is likely a volatile situation. Therefore, prior to calling security, make sure you’re doing it for the right reasons, which may include following policy, protecting your ability to take care of the patients without distraction, or protecting privacy.

Technology isn’t going away, and just like we’re starting to see more police officers with cameras attached to them, there certainly may come a time when we see more recordings of the physician-patient interaction. I can’t remember the last time a patient wanted to record my interaction with them or that someone in my group mentioned it to me, so for now, I still think we’re early in this evolution. Therefore, we can go ahead and work on developing policies with our administration that take into account some of the patients’ desires while protecting the hospital, staff, and other patients.

No matter the setting, all healthcare professionals “records” what goes on when dealing with a pt… it is called “the pt’s medical record” and unless there is something that proves or refutes what was actually done… then the healthcare professional’s beliefs, opinions, “lies” that are put in the pt’s medical record will be considered “the truth”.

Without a video/audio recording.. there can be three sides to every story… mine, yours and THE TRUTH. Without a audio/video recording… it will be the healthcare professional’s input in the pt’s medical record that will probably prevail.

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Express Scripts mail-order pharmacy to limit opioids

www.ktar.com/story/1696130/express-scripts-mail-order-pharmacy-to-limit-opioids/

The nation’s largest pharmacy benefit manager will soon limit the number and strength of opioid drugs prescribed to first-time users.

The move by Express Scripts, which has offices in Tempe, was part of a wide-ranging effort to curb an epidemic affecting millions of Americans.

But the new program has drawn criticism from the American Medical Association. The organization said doctors and patients should decide the course of treatment.

Express Scripts wants to limit prescriptions to seven days for first-time users and require short-acting opioids.

The Missouri-based company also wants to monitor for potential abuse. The program excludes hospice, palliative care and cancer patients.

A competitor, CVS Caremark, has a similar program.

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Flimsy evidence behind many FDA approvals

https://in.reuters.com/article/us-health-fda-approvals-idINKCN1AV23K

(Reuters Health) – Many drugs granted accelerated approval by the U.S. Food and Drug Administration (FDA) lack clear evidence of safety and effectiveness, and the same is true for most high-risk medical devices, according to two new reports in the Journal of the American Medical Association.

The Accelerated Approval pathway makes potentially promising investigational medicines available for use before the usual amount of data has been collected to confirm their effectiveness and safety, Dr. Huseyin Naci from the London School of Economics and Political Science told Reuters Health by email.

“Drugs granted Accelerated Approval should be rigorously evaluated using convincing patient-centered clinical outcomes in rigorous studies,” Naci said. But, he added, “we have found numerous situations in which required confirmatory studies with rigorous designs and outcomes are not pursued or are not completed in a timely fashion, and in these cases, we are concerned that regulators appear to accept data that would not otherwise meet FDA standards.”

Naci’s team analyzed the FDA’s accelerated approval of 22 drugs for 24 medical conditions.

For standard approval, the FDA generally requires gold-standard randomized controlled trials (RCTs) that demonstrate a drug’s safety and effectiveness. Fourteen of these accelerated approvals, however, were exclusively based on less-rigorous trials.

Given the lower standard of evidence, the FDA required 38 more trials after approval to confirm the benefits of these drugs. Three years after approval, though, only 19 had been completed. Eleven more were underway and said to be on schedule, six others were delayed by more than 12 months, and two had been discontinued.

Most of these later trials still used outcomes that would not be acceptable for standard approval, and several studies failed to show a benefit or were terminated early.

For the 10 approvals that finally met the requirements established by FDA, the time to do so ranged from one to five years after the accelerated approval.

“Our findings suggest that expediency in drug development and approval can be successful but that drugs approved via the shorter route to market are rarely subject to tests even in the post-approval period that use established and clinically meaningful outcomes,” Naci said.

When the FDA approves medicines via its Accelerated Approval pathway, he said, the agency should clearly specify the data limitations and how required confirmatory studies are expected to compensate for these limitations.

A second report from Dr. Rita F. Redberg from the University of California, San Francisco, and colleagues paints a similar picture when approval is needed for modifications to high-risk medical devices.

“We expected to find generally high-quality evidence to support these changes, because these devices are important to health, and many are implanted and are difficult and/or dangerous to remove,” Redberg told Reuters Health by email. “We were surprised to discover that relatively few studies were randomized or blinded, which means that it is not known if the device was better than an alternative treatment (or better than no treatment), and whether any purported beneficial effect was actually due to the well-documented placebo effect of procedures and devices.”

“In addition, we were disturbed to find numerous discrepancies between the number of patients enrolled and the number of patients with data reported, indicating that there is loss (or incompleteness) of data evaluated by the FDA,” she said. “This raises concerns about missing data and selection bias.”

Of the 78 device modifications they studied, 71 were supported by a single clinical study, and half of these enrolled 185 or fewer patients. One in 12 studies did not specify what the researchers were looking to prove.

“I think the public assumes that medical devices currently on the market, particularly high-risk devices, have been approved based on a high standard to show safety and effectiveness before doctors can recommend and implant them,” Redberg said. “Our findings show that this assumption is often incorrect.”

Dr. Robert M. Califf from Duke University School of Medicine, Durham, North Carolina, who wrote an editorial related to these reports, told Reuters Health by email, “People should ask their doctors about the evidence for drugs and devices being prescribed or use, and they should support research and participate. In addition, they should encourage their doctors to participate; too many doctors just ‘go with the flow’ rather than demanding high-quality evidence about what they are prescribing and implanting, and actively joining into appropriate clinical trials.”

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California Hospital Sued for Refusing to Assist Suicide

www.nationalreview.com/corner/450438/california-hospital-sued-refusing-assist-suicide

This lawsuit is a little before its time. Should assisted suicide become widely accepted in this country, activists will try to force all doctors to participate–either by doing the deed or referring to a doctor known to be willing to lethally prescribe. But it isn’t yet, and so the pretense of the movement that they only want an itsy-bitsy, teensy-weensy change in mores and law continues as SOP. But sometimes they show their true intentions. Thus, when UCSF oncologists refused to assist a cancer patient’s suicide, the woman died of her disease. Now, her family is suing–using the same attorney (Kathryn Tucker) who tried (unsuccessfully) to obtain an assisted suicide Roe v Wade in 1997 and has brought other pro-assisted sucide cases around the country. From the San Francisco Chronicle story: Judy Dale died of cancer in her San Francisco home in September, in agony, after being denied the pain-relieving medication she might have received under the state’s aid-in-dying law that had taken effect three months earlier. Bias alert! Pain relieving medication is palliative, to ease pain or other very uncomfortable. Dale was not issued a lethal prescription intended to kill her. That’s not the same thing. Back to the story: A lawsuit by her children will determine whether UCSF Medical Center, where Dale first went for treatment, was responsible for her suffering by allegedly concealing its oncologists’ decision not to provide life-ending drugs to patients who ask for them. More broadly, their suit illuminates the inner workings of a law that confers new rights on terminally ill patients, but few obligations on their health care providers. Specifically, doctors and hospitals are provided clear and explicit conscience protections in the law. No hospital or physician can be forced to participate or refer in an assisted suicide Demonstrating the disingenuousness of the lawyers bringing suit, that provision was–as the story reports–required to induce the California Medical Association to go neutral on the law, without which it almost surely would never have passed. The primary claim is elder abuse. If that theory prevails, not helping kill a patient would become a form of abuse! Unthinkable. The plaintiffs also contend that the hospital had assured Dale she would be able to receive assisted suicide, and then failed to follow through. I don’t know if that kind of statement would be actionable or not since there is no legal duty to do the deed, as it were. But this I do know: The lawsuit illustrates where the assisted suicide/euthanasia movement wants to go. As in Ontario, Canada, they want doctors and hospitals to be forced to participate in assisted suicide or get out of medicine.

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Strict limits on opioid prescribing risk the ‘inhumane treatment’ of pain patients

www.statnews.com/2017/02/24/opioids-prescribing-limits-pain-patients/

Amid a rising toll of opioid overdoses, recommendations discouraging their use to treat pain seem to make sense. Yet the devil is in the details: how recommendations play out in real life can harm the very patients they purport to protect. A new proposal from the Centers for Medicare and Medicaid Services to enforce hard limits on opioid dosing is a dangerous case in point.

There’s no doubt that we needed to curtail the opioid supply. The decade of 2001-2011 saw a pattern of increasing prescriptions for these drugs, often without attention to risks of overdose or addiction. Some patients developed addictions to them; estimates from the Centers for Disease Control and Prevention range from 0.7 percent to 6 percent. Worse, opioid pills became ubiquitous in communities across the country, spread through sale, theft, and sharing with others, notably with young adults.

The prescribing tide has turned: Private and governmental data show that the number of prescriptions for opioids has been falling since 2012. Reassuringly, federal surveys show that misuse of pain relievers bottomed out in 2014-15.

Nevertheless, the CDC produced a guideline in 2016 that recommended shorter durations for opioid prescriptions and the use of non-drug treatments for pain. It also suggested keeping opioid doses lower than the equivalent of 90 milligrams of morphine. As the guideline acknowledged, its recommendations reflected weak scientific evidence. Problematically, it was silent on how to care for patients already receiving doses higher than the 90 milligram threshold.

Unfortunately, these mitigating features were undermined by intemperate publicity that vilified opioids for pain. Opioids for pain “are just as addictive is heroin,” proclaimed CDC Director Dr. Tom Frieden. Such statements buttress a fantasy that the tragedy of opioid overdoses and deaths will be solved in doctors’ offices, primarily by upending the care of 5 to 8 million Americans who receive opioids for pain, even when most individuals with opioid addiction did not start as pain patients.

The progression of the guidelines from “voluntary” to “enforceable” has culminated in a draft policy from CMS. It would block all prescriptions above the CDC threshold of 90 milligrams unless complex bureaucratic barriers are surmounted. Many pharmacy plans are already enforcing this approach. Under that plan, many patients suffering with chronic pain would lose access to the medicines they are currently taking, all in the name of reversing a tide of death increasingly defined by non-prescribed opioids such as heroin and fentanyl.

The logic of doing this is untested. There have been no prospective clinical studies to show that discontinuing opioids for currently stable pain patients helps those patients or anyone else. While doing so could help some, it will destabilize others and likely promote the use of heroin or other drugs. In effect, pain patients currently taking opioids long-term have become involuntary participants in an experiment, with their lives at stake.

Turning the voluntary guidelines into strict policy is unfortunate for three reasons.

Second, we have alternatives to bureaucratic controls. These include promoting and paying for treatments that de-emphasize pills. Important work by the Department of Veterans Affairs shows how to identify patients with elevated risk for harm from opioids and how to mitigate the risks.

Third and most troubling is the increasingly inhumane treatment of patients with chronic pain. Fearing investigation or sanction, physicians caring for patients on long-term opioids face a dire choice: to involuntarily terminate prescriptions for patients who are otherwise stable, or to carry on as embattled, unprotected professionals, subject to bureaucratic muscle and public shaming from every direction.

In this context, we cannot be surprised by a flurry of reports, in the press, social media, and the medical literature describing pain patients entering acute withdrawal, losing function, committing suicide, or dying in jail. The CMS policy, if adopted, will accelerate this trend.

Many of our colleagues in addiction medicine tell us they are alarmed by the widespread mistreatment of pain patients. We receive anecdotes every week from physicians and pharmacists, most of them expert in addictions, describing pain patients who have involuntarily lost access to their pain medications and as a result have been reduced from working to bedridden adults, or who have become suicidal.

This loss of access occurs several ways. A pharmacy benefit program may refuse to cover the prescription because it has already enacted the changes that CMS is proposing to make mandatory. A physician may feel threatened by employers or regulators, and believes his or her professional survival depends on reducing opioid doses — involuntarily and without the patient’s consent — to thresholds that the CDC itself described as voluntary and not mandatory. Or state regulators have imposed such burdensome requirements that no physician in a given region can sustain prescriptions for their patients. Such patients are then “orphaned,” compelled to seek treatment from other physicians across the country.

Given the expertise in addiction among these physicians, it should be particularly worrisome that they believe the present pill-control campaign has gone too far. And yet, the ethics are clear: It should never be acceptable for us to countenance the death of one patient in the avowed service of protecting others, even more so when the projected benefit is unproven.

Surgeon General Dr. Vivek Murthy made an underappreciated declaration in a recent interview with the New England Journal of Medicine. “We cannot allow the pendulum to swing to the other extreme here, where we deny people who need opioid medications those actual medications. … We are trying to find an appropriate middle ground,” he said.

As addiction professionals, we agree wholeheartedly.

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Oligoanalgesia in the emergency department

http://www.medscape.com/medline/abstract/2803357

Oligoanalgesia: Underuse of analgesics in the face of valid indications–eg, intense bone pain of terminal CA–for its use.

A review of the charts of 198 patients who were admitted through the emergency department with a variety of acutely painful medical and surgical conditions revealed that 56% received no analgesic medication while in the emergency department. In the 44% of patients who received pain medication, 69% waited more than 1 hour while 42% waited more than 2 hours before narcotic analgesia was administered. In addition, 32% initially received less than an optimal equianalgesic dose of narcotic when compared with morphine. This study demonstrates that narcotic misues, in the form of oligoanalgesia, is prevalent and is the shared responsibility of both emergency physicians and housestaff consultants.

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New Ky. law limits prescriptions for certain pain meds to 3-day supply

http://www.wdrb.com/story/35790831/new-ky-law-limits-prescriptions-for-certain-pain-meds-to-3-day-supply

LOUISVILLE Ky. (WDRB) — A new law that limits how much pain medicine doctors can prescribe in Kentucky is now in effect. 

The new law that took effect Thursday is designed to help fight the opioid epidemic that’s sweeping the nation. Under the new law, prescription painkillers will be limited to a 3-day supply in an effort to prevent abuse. 

The idea behind HB 333 is to prevent extra opioid pain pills from entering the illegal drug market. The bill underwent intense debate by Kentucky lawmakers before it was passed earlier this year. 

The bill’s sponsors say the goal is to get drugs like fentanyl and carfentanyl off the streets and out of the hands of drug traffickers. Penalties for anyone caught trafficking the drugs are now elevated to a Class C Felony for a first offense. 

The biggest concern over the new law centers on the 3-day pain pill limit, which prohibits doctors from issuing a prescription for more than the three days for Schedule II narcotics like OxyContin. 

Some patients who truly need the medication say the law makes it too difficult for them to get pain medication for legitimate reasons. 

The law does include exceptions for cancer patients, people diagnosed with chronic pain and patients receiving end-of-life care.

  How bright does a politician have to be to come to the conclusion that by limiting the legal prescribing of opiates will somehow stop the flow of ILLEGAL OPIATES from being on the street ?

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I know that my blog has been very quite for a few days..  Last Thursday we drove from our Indiana home to Durham, NC (550 miles) to visit with our Daughter and grandson and to celebrate our Daughter’s birthday – which is actually today (Aug 15). My laptop and IPad remained safely in my backpack.. I didn’t even attempt to get them out…  I tried to scan my emails using my phone and “trashing” the emails that were more or less spam..

I went “cold turkey” and really didn’t have any side effects.. of course keeping up with a 10 y/o grandson.. there was no time to think about anything… we were either “going” or trying to “recover” from all the “going”

Monday we took off for our beach home – 800 miles –  This sweet  little girl ( 7 y/o Shih Tzu name Cuddles) in the picture, lost her “forever home” on July 15th when her Daddy (James) died.

None of his adult children wanted her and before she could be tossed into the “recycle bin” we reached out to his “girl friend” offering to “rescue her”.

We had been friends with her Daddy and her Mommy – who died in May 2011 – for over two decades.

This is not the best picture of her, she apparently doesn’t like to have her picture taken… and there are really two eyes in that “black mask” on her face, but today we “officially” adopted her and she is in her last “forever home”. And she can continue to live in the style which she had become accustomed to.

We still have to find out what kind of “traveler” she is… since James did not travel with her except to the vet and groomer and within a week we will be head back to Indiana with another long (650 mile) trip.  It may end up being a new experience for all of us 🙂

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Zynerba Shares Plunge as Cannabis-Based Epilepsy Gel Fails Study

https://www.doximity.com/doc_news/v2/entries/8719011

Zynerba Pharmaceuticals Inc’s stock lost more than half its value on Monday after the U.S. drug developer said its synthetic cannabis-based gel for epilepsy failed a mid-stage study.

Zynerba’s gel contains a synthetically processed formulation of cannabidiol (CBD), a non-psychoactive component of the cannabis plant.

Although many U.S. states have sanctioned the medical and/or recreational use of cannabis, drugs derived from the plant could take longer than others to hit the market.

Under U.S. federal law, marijuana is considered a dangerous substance with no medicinal value, making additional approvals for marijuana-derived treatments necessary prior to launch.

Two doses of Zynerba’s ZYN002 gel were tested against a placebo in the study.

Neither dose induced a statistically significant improvement in seizure frequency versus the placebo in patients who were already on up to three anti-epileptic medications.

The 188-patient study comprised adults suffering from epilepsy with partial seizures, which occurs when epileptic activity takes part in a localized part of the brain.

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FDA Warns Against Use of Any Liquid Product From PharmaTech

http://www.medscape.com/viewarticle/883981

Clinicians and patients should not use any liquid product manufactured by Pharma Tech LLC and distributed by Rugby Laboratories because of Burkholderia cepacia contamination and the potential for severe patient infection, the US Food and Drug Administration (FDA) advised today in a safety communication. 

Dicto Liquid. Photo courtesy of the FDA

On August 3, Rugby Laboratories, of Livonia, Michigan, announced a voluntary recall of two oral liquid docusate products — Diocto Liquid and Diocto Syrup — manufactured by PharmaTech, of Davie, Florida.

“Additional liquid drug products manufactured by PharmaTech might also be affected. Such products might have been labeled and distributed by Rugby and other companies. Any company that purchased liquid products manufactured by PharmaTech should immediately quarantine material under their control and contact the local FDA pharmaceutical recall coordinator,” the FDA advised.

The agency acknowledges that it might be tough to determine the manufacturer because these liquid products are not labeled with a PharmaTech label. Healthcare facilities and pharmacies that think they might have liquid PharmaTech drug products, especially oral liquid docusate drug products, should check with their supplier to determine who manufactured the product, the FDA said. 

According to the FDA, laboratory testing of PharmaTech’s oral liquid docusate, conducted by the Centers for Disease Control and Prevention (CDC), found a strain of B cepacia, which has been linked to recent infections in patients.

In 2016, the CDC and the FDA advised against using any liquid docusate drug products.

An investigation into a 2016 multistate outbreak identified B cepacia in more than 10 lots of oral liquid docusate sodium manufactured by PharmaTech, which was linked to patient infections that required intensive medical treatment. The 2016 investigation also detected B cepacia in the water system used to manufacture the product, the FDA said.

This year, the agency said it has received reports of “several adverse events” related to oral liquid docusate sodium products. 

Healthcare professionals are encouraged to report problems related to these products to the FDA’s MedWatch Safety Information and Adverse Event Reporting Program. 

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