Central PA Medicine Spring 2021 - 16

dauphincms.org
Features
MEDICATION ERRORS
ARE THE LEADING
CAUSE OF HARM
TO OUR GERIATRIC
POPULATION.
on a geriatric census are, our patient was
on several different medications to control
her various comorbidities. Her pills were
prepacked for her by her pharmacy into a
daily pill box with separate boxes for each
day, as well as morning, noon, and night.
On Monday morning the patient's
caregiver had called the office requesting
a home visit as soon as possible. When the
caregiver had arrived at the patient's house
that morning, she had found the patient
on the floor with a wound on her forehead.
The patient was not able to tell the caregiver
the details of the fall or when during the
weekend it had occurred but due to her
hemiparesis, she was unable to get herself
off the ground.
The visiting medical team went straight
to the patient's home that morning and
thankfully found the patient well aside
from her forehead abrasion. She appeared
to be in her normal state and was acting
appropriately. The rest of her physical exam
only revealed elevated blood pressure. In
an attempt to elucidate the cause of the
patient's weekend mishap the medical
resident went through the patient's entire
pill box and using an extensive internet
search went through and discovered that
the patient's pill box had been missing both
her Keppra and her Norvasc. Likely what
had happened was that the patient suffered
a seizure causing the fall, explaining why
she could not remember the details. It
also explained the patient's elevated blood
pressure. The pharmacy was contacted to
replace the missing medications.
The following week the patient was again
visited by the team. Her pill box was again
investigated using a google search to identify
and ensure all prescribed medications
were in the box. The patient had had no
further incidents and the pill box proved
correct. Her forehead abrasion had almost
completely healed, and her blood pressure
had returned to normal.
This story exemplifies a medication
administration error that could have been
far worse than it was. Our patient has
significant help with her medications and
daily life and still this error occurred. The
internet search to identify each individual
pill was pain staking even for two medical
residents. Something our cognitively impaired
patient certainly would not have been
capable of doing. If this were not identified
as an issue with missing pills, and instead
was treated by up-titrating medication or
adding second agents, this patient could
have suffered further harm.
Medication errors are the leading cause
of harm to our geriatric population. They
are particularly at risk for polypharmacy as
they usually have several medical conditions
requiring multiple pharmacological interventions.
This is further compounded by
the fact that pharmacokinetics are altered in
this population and they are often excluded
from pharmaceutical trials.
This patient taught us how something
quite simple can potentially have catastrophic
consequences. Likely, the error at
the pharmacy was not a malicious attempt
to harm the patient. It was simply an
omission of two of the patient's several
daily medications. Thinking through the
probable causes of this patient's fall and
hypertension is what lead us to consider
a medication error and look through
the pill box. Often taking a step back
and considering the most common-sense
approach to every problem is the most
helpful. Especially when, instead of being
at a hospital with an interdisciplinary team
and all the resources you could desire at
your fingertips, you find yourself inside a
patient's home.
16 Spring 2021 Central PA Medicine
http://www.dauphincms.org
Central PA Medicine Spring 2021

Table of Contents for the Digital Edition of Central PA Medicine Spring 2021
