Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local teaching hospital. When discharged, he was instructed to "resume" taking torsemide, although he had never taken this powerful diuretic previously. In his first follow-up appointment with his usual physician at the VA outpatient clinic, he requested a refill of the torsemide. His medication record showed that he had been taking terazosin for benign prostatic hyperplasia prior to the hospitalization; there was no record of his being on torsemide. When questioned about it, the patient said he had told the emergency department (ED) staff that he was taking a medicine whose name started with the letter T to make him urinate. The ED staff had entered torsemide into the electronic medical record. When discharged, this came up as an at-home medication, and he was instructed to resume taking it. When he came to see his primary MD at the VA clinic requesting a medication he didn't need and hadn't taken before, the error was detected.
Case 2. At another local teaching hospital, a family had given incorrect data to the ED staff (including listing the patient as being on prednisolone rather than prednisone), and the physicians caring for the patient had simply checked off the option to continue the home medications. When the records were carefully reviewed by a physician consulting for an upcoming cardiac procedure, almost all of the medications were found to be incorrect. Had the cardiologist assumed that the other physicians and nurses had accurately entered the medications, the errors would have gone undetected, and the patient's chronic steroid dependence might have not been appropriately addressed perioperatively. Fortunately, no harm occurred.
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