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Cases & Commentaries
- Web M&M
Candy Tsourounis, PharmD, and Katayoon Kathy Ghomeshi, PharmD; July 2019
An elderly man admitted for agitation and suicidal ideation was prescribed clozapine by psychiatry. The clozapine Risk Evaluation and Mitigation Strategy (REMS) program requires both prescribers and patients to be registered in an online database. A REMS-registered attending psychiatrist entered the initial order (12.5 mg). During the hospitalization, the medicine intern, who was not registered with the REMS program, titrated the dose to 25 mg daily and also wrote the discharge prescription. The outpatient pharmacist noted the intern was not registered and contacted the attending psychiatrist, who wrote a new prescription. The patient's family was unable to pick up the prescription for 3 days. During this gap in therapy, the patient experienced recurrence of paranoia and required readmission to the hospital.
Dao J, Carey B, Frosch D. New York Times. February 13, 2011;A1.
This newspaper article reports on the risks of polypharmacy in veterans and discusses the need to improve monitoring to prevent fatal medication errors.