A case report published in the journal The Consultant Pharmacist illustrates the importance of a comprehensive medication review after a patient was prescribed the wrong medication for over a decade.

The case involved a 69-year old patient with paranoid schizophrenia who was brought to the emergency department following violent behavior against the staff at the nursing facility he resided in. A diagnosis of urinary tract infection was made and the patient was subsequently moved to the behavior health unit. As his cognitive function was poor, the patient was unable to confirm the medications he was taking so a chart review was initiated by one of the pharmacy students.

During the review, it was revealed that a transcription error had occurred 10 years prior; a prescription for amantadine 100mg twice daily had been deleted and amiodarone 100mg twice daily had been added. In addition, during another hospitalization, rather than uncovering the error, the dose of amiodarone was increased to 200mg twice daily. 

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After electrocardiograms showed that the patient was negative for atrial fibrillation, he was taken off amiodarone and a letter was sent to his primary care doctor alerting of the change. However, upon admission 4 months later, it was revealed that the patients had been restarted on amiodarone at the nursing facility. The drug was again discontinued and the facility was again notified of the change. 

“A 10-year-old medication error went undetected in the electronic medical records through numerous medication reconciliations, but was uncovered when a single comprehensive medication review was conducted,” the authors concluded.

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