Pet Meds Listed in Owner’s Medication Profile Lead to Confusion in the ED

A recent report describes the case of a patient whose pet medications were listed within her external medication history list of the electronic medical record (EMR) and highlights the importance of verifying and validating medication lists through interviews with the patient or patient’s family as well as prescription history refills.

The patient, a 67-year-old female, presented to the emergency department (ED) with altered mental status. The patient’s medical history included depression, Parkinson disease, diabetes, and hypertension. Upon presentation, the patient was hyperthermic (38.4 degrees Celsius), tachycardic (140 beats/minute), and hypertensive (systolic blood pressure in the 220s). All laboratory findings were within normal limits and her toxicology screen came back negative.

While in the ED, the patient experienced a seizure and rapidly became unconscious. The emergency medicine clinical pharmacist was then consulted in order to determine whether her symptoms were drug related.

The pharmacist completed a medication history by conducting family member interviews as well as reviewing the patient’s medication bottles. An external prescription refill report, which is reported in the EMR, was obtained to confirm the information that was provided.

The pharmacist determined that there was a possibility that the patient had missed doses of her carbidopa-levodopa, which could potentially lead to neuroleptic malignant syndrome. However, the patient’s medical history also listed 2 medications, phenobarbital 50mg twice daily and zonisamide 200mg every 12 hours, which could not be confirmed by her family. “This was concerning as the ED differential for the patient’s alteration in mental status included barbiturate withdrawal and status epilepticus,” the authors explained.

The patient’s family adamantly denied that the patient had a history of seizures, despite having one in the ED. After the family reported that the patient’s dog had a seizure disorder, it was verified that the 2 prescriptions were actually pet medications which had been registered to the patient’s name and date of birth in order to fulfill the state’s prescription monitoring program (PMP) requirements.

The patient’s medications were then reconciled and correctly documented in her EMR after an accurate medication history was obtained. Although no definitive diagnosis was made, the patient’s altered mental status was attributed to neuroleptic malignant syndrome. The patient was treated and discharged 9 days after her presentation to the ED at her baseline cognitive function.

“A lack of standardization between pet identifiers required to create pet profiles in community pharmacy databases and state Board of Pharmacy regulations for PMPs has led to the association of pets’ medications with their owners in the EMR,” the authors noted. To prevent similar cases, they recommended that “Patient medication lists should always be verified and validated utilizing patient or patient family interviews and prescription refill histories.”

Reference

1.      Nguyen TT, Kirkwood CF, Reilly D, Lee D, Coggin C. Pet medications: a tail of caution [published online November 9, 2020]. J. Pharm. Pract. 2020. doi: 10.1177/0897190020966149.