Dangerous Road Ahead

More than 1 in 10 patients are harmed in the course of their medical care…………..and half of those injuries are preventable. 

And there she was, by the time she reached the inpatient geriatric psychiatry inpatient ward in serotonin syndrome delirium, Ms. X was on Lexapro, Prozac, Effexor, Risperidone, Ingrezza, Austedo and Trazodone according to medication reconciliation. Records from the two recent hospitalizations in the last 3 days indicates each time the medication reconciliation was completed, old and other medications were added, ordered, and administered. Case in point the article (1) where it reports on a study (2) that reports:

“We need strategies in place to detect and correct the key causes of patient harm in health care.” “Our study finds that most harm relates to medication, and this is one core area that preventative strategies could focus on.”

            Researchers sought to determine the prevalence of preventable patient harm in hospitals, primary care, and various specialties. They used a systemic review and meta-analysis to estimate the prevalence of harm from five electronic databases and a pooled sample of 337,025 patients (3). Like the case highlighted above, incidents relating to drugs and other therapies accounted for 49 percent of the harms, and injuries related to surgical procedures accounted for 23 percent. The above case is highlights the preventable nature of such errors. Had attention to detail been paid, Ms. X would not have been subjected to the poly-pharmacy that caused the delirium. There is evidence that up to 30% of the cases of delirium in elderly hospitalized patients is caused by medication toxicity to include psychotropic medications (4). The current case highlights a learning point described by Kosari SA (2014)(5):

“Delirium is a multifactorial disorder that can be precipitated by any medical condition in a susceptible person, therefore a comprehensive history and physical (H&P) examination is imperative to guide diagnostic investigations.”


  1. https://www.nbcnews.com/health/health-news/medical-mistakes-harm-more-1-10-patients-many-are-preventable-n1030996
  2. Panagioti Maria, Khan Kanza, Keers Richard, Abuzour Aseel, Phipps Denham, Kontopantelis, Evangelos et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis BMJ 2019; 366 :l4185, https://www.bmj.com/content/366/bmj.l4185
  3. https://www.healthexec.com/topics/quality/medical-mistakes-harm-1-20
  4. Moore, A.R. & O’Keeffe, S.T. Drugs & Aging (1999) 15: 15. https://doi.org/10.2165/00002512-199915010-00002
  5. Kosari SA, Amiruddin A, Shorakae S, Kane R. A rare cause of hypoactive delirium. BMJ Case Rep. 2014;2014:bcr2014205382. Published 2014 Oct 19. doi:10.1136/bcr-2014-205382

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