WebM&M: Case Studies

This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

A 55-year-old man visited his oncologist for a follow-up appointment after completing chemotherapy and reported feeling well with his abdominal and bony pain well controlled with opioid therapy.  At the end of the visit, his oncologist reordered his pain medication and, due to a best practice alert, also prescribed naloxone but failed to provide any instruction on its use. Later that day, the patient took the naloxone along with his opioid pain medication and within a minute experienced severe abdominal and bony pain, requiring admission to the emergency department.

Presenting with a cough and shortness of breath, a woman with end-stage renal disease was admitted to the medical floor after undergoing hemodialysis. She was given allergy and sleep medications at her home dosages. The next morning the patient was extremely drowsy and unresponsive to painful stimuli. A "Code Stroke" was called.

For a woman with insulin-dependent diabetes mellitus, the admitting medical team ordered sliding scale insulin. Her blood glucose levels became very difficult to control, and she developed diabetic ketoacidosis. In the morning, the physician instituted a more appropriate insulin regimen.

A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.