What’s New in the Patient Safety World

February 2018

10 Years on the Wrong Medication



We’ve often seen patients on unnecessary medications for long periods. The offending agents we’ve seen most often are PPI’s (proton pump inhibitors) or other drugs used to reduce gastric acid. These are often started while patients are in an ICU when there may be an appropriate indication. However, prophylactic gastric acid reduction is really only indicated while those patients are critically ill and those drugs should be discontinued once the patient is transferred out of the ICU. Unfortunately, medication reconciliation at the time of transfer and at the time of subsequent hospital discharge often fails to uncover that such drugs are no longer necessary. And at follow up, if there has been inadequate communication, the primary care physician may be reluctant to discontinue a medication that had been started during a hospitalization. Hence, we’ve seen patients unnecessarily receiving such medications for several years.


But we’ve never seen a case as long as 10 years. Recently, a case study was published in which a patient received the wrong medication for 10 years (Comer 2017)! A 69-year old man with schizophrenia was admitted to a hospital because of violent behavior. Because of poor cognitive function and inability by the patient to provide a good medication history, the pharmacy student on rotation performed an in-depth chart review. The review revealed a transcription error in 2003 deleting amantadine 100 mg twice daily and adding amiodarone 100 mg twice daily, later increased to 200 mg twice daily. A consulted cardiologist discontinued the amiodarone, and the primary care provider was notified via letter and discharge papers but on a subsequent admission four months later it was revealed that the nursing facility restarted the amiodarone. Amiodarone was discontinued and the facility was again notified.


This case demonstrates several important points. First, it illustrates how the medical record (either electronic or paper) can propagate medication errors over a long run. Second, it illustrates that medication reconciliation is not infallible (since several opportunities to identify this error failed to do so). Third, it emphasizes the need for regular comprehensive reviews of medication regimens (such as the annual “brown bag” review). And fourth, it emphasizes the need for a communication other than a discharge summary or letter in order to ensure that an incorrect or unnecessary medication is not restarted.






Comer R, Lizer M. Medication Review and Transitions of Care: A Case Report of a Decade-Old Medication Error. The Consultant Pharmacist 2017; 32(10): 7-12







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