The Pharmacy Times has written a story on the Institution for Safe Medication Practices’ (ISMP) report that it continues to receive cases where Methotrexate has been given in place of another drug by mistake, leading to a fatality.
Methotrextate is a disease-modifying anti-rheumatic drug (DMARD), which can be given for various types of arthritis. As with all medications, taking unprescribed medication can be extremely harmful or even fatal in a worst-case scenario. Here are two case studies shared by the Pharmacy Times to highlight this fact:
Case Study 1
An elderly patient had Paxil (paroxetine) prescribed for depression, and a thirty-day supply was requested. it is presumed that Trexal (methotrextate) was allegedly dispensed instead of Paxil. The two differing medications had the same strength of 10mgs and the error was not identified, nor reportedly was the patient advised on her new medication upon collecting it.
Sadly, the patient was unaware that the dispensed medication was not the drug she had been prescribed, as the label on the box matched that of the methotrexate inside, not the drug that was actually prescribed. The patient adhered to the dosage of one tablet daily and was admitted to hospital feeling severely ill after seven days, and she died in intensive care within a week.
This, apparently, is the first report of a mix-up based on these two branded names, but it does not lessen the extremely unfortunate consequences of it.
Case Study 2
This story made news articles when it occurred. A patient in an assisted-living facility was given methotrexate instead of metolazone. The pharmacy had allegedly sent the wrong prescription to the facility and the error was not picked up on.
The drug was administered to the patient who eventually began experiencing pain and severe discomfort. After roughly one month of receiving daily doses of the medication, the patient died.
How do mix-ups happen?
Mix-ups can happen for a multitude of reasons, from similar-sounding drug or brand names, drug strengths that match, or placement on shelves in relation to similar sounding or looking names.
Then there is simple human error on either the prescribing or dispensing side, or both, and of course, lack of proper procedure or errors made due to an unhealthy working environment.
Further reading
Please see our guide to Prescription or Medication Errors.
WHAT TO DO NEXT
If you or a loved one under your care have experienced negative consequences to your health as the result of a dispensing or prescribing error, get in touch today for a free initial consultation. Choose one of the methods on the right-hand side of this page, or call us on 0113 200 9787 to find out how we can help you.
Article by Stuart Jones
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