Page 30 - Risk Reduction Series Effective Systems Part 2

SVMIC Risk Reduction Series: Effective Systems

CASE STUDY

continued
over the next two months. At each visit, the patient was
asked if he was on the “same dose” of medication rather

than specifically asking him how much he was on. The

office notes for these visits indicated he was taking
Amiodarone 200mg two times per day instead of the
actual dose of 400mg three times per day. The patient’s

symptoms worsened, and he experienced an increase in

weakness, dizziness, and gait instability, so carotid studies
and liver function tests were performed, but follow-up
of the lab results was not done. Two months later, which

was now four months after the patient’s discharge, the

patient’s nephrologist identified the discrepancy in the
patient’s medication record and the abnormally high
dose of amiodarone that was on the patient’s medication

bottle brought into that visit. The nephrologist phoned

the cardiologist to verify that the patient should be on this
much medication.

The cardiologist told the nephrologist to have the patient
immediately discontinue the medication. A few weeks

later, the patient was admitted with ongoing symptoms of
weakness, dizziness, and gait instability.

He suffered a stroke, pneumonitis, and
polyneuropathy and expired one month

later due to the effects of the toxicity.

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