WebM&M: Case Studies

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.

After entering an electronic prescription for the wrong patient, the clinic nurse deleted it, assuming that would cancel the order at the pharmacy. However, the prescription went through to the pharmacy, and the patient received it.

With no one to interpret for them and pharmacy instructions printed only in English, non–English-speaking parents give their child a 12.5-fold overdose of a medication.

A woman given is found cyanotic on morning rounds. Her methemoglobinemia is determined to be from a roughly 7-fold overdose of dapsone.

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