An unusual case from France has highlighted the importance of medicine reconciliation, say experts
A 66-year-old man with cirrhosis and chronic alcoholism was accidentally prescribed his dog’s medication when admitted to hospital.
The problem arose when the patients’ GP added 1g/day of valproate to his regular prescription.
This was intended as a treatment for his epileptic dog, but was added to the script to be covered by French national health insurance, said the authors, who included pharmacy academics.
However on admission to hospital for cardiac valve surgery the valproate was taken to be part of his regular treatment regime and administered to the patient.
He experienced greatly increased plasma potassium levels and a progressive increase in liver enzymes causing the delay in his surgery until the error was discovered and the adverse events rectified.
The case “highlights the imperative need to strictly control indications of home drugs administered during hospitalisation and the damaging consequences of the inappropriate use of reimbursement systems,” said the authors.
It also emphasises the important role that all health professionals – GPs, pharmacists, physicians – have to play in preventing the diversion of prescription drugs and limiting the risk of adverse drug events, said the report authors.
The case was reported in the journal Drug Safety.