Clinical Geriatrics

Case Presentation

AG, a 75-year-old Hispanic female, was informed by the receptionist in the waiting room of her primary care clinic that the physician with whom she had an appointment was available to see her. She had been attending this multispecialty teaching clinic regularly and was accustomed to seeing new resident physicians from different specialties. AG was sent to the office of the psychiatry resident who had recently started the clinic rotation and was scheduled to see a patient “AG” that afternoon. The resident had reviewed AG’s chart prior to asking the receptionist to call her, and was prepared to meet with an elderly woman who had been experiencing improvement in a depressive episode in association with antidepressant treatment. AG entered the resident’s office accompanied by her home health aide and a translator, whom the clinic provided because of AG’s limited fluency in English.

The resident introduced herself and explained that she was AG’s new psychiatric resident. The resident inquired about symptoms of depression, and the patient reported that she did not feel depressed and added that she had only come to the clinic for this scheduled follow-up to receive a refill for her “blood pressure medications.” Through the translator, the resident confirmed that AG did not have any side effects related to the antidepressant listed in the chart. Assessment of AG’s cognitive status revealed that she could not recall the precise date and could not name all of the medications that she was taking, but that she was oriented to place and person, and appeared to have relatively intact cognition aside from a mild recent memory deficit.

The resident inquired further about AG’s medications, and then asked to see her medication bottles. AG produced the two nearly empty bottles of her antihypertensive medications and said that she had left the bottles of the other medications she was taking at home. The bottles of antihypertensive medications corresponded to those listed in her chart. AG was asked about the antidepressant that was also noted in the chart, but both AG and her aide stated that they could not recall the names or purposes of her other medications. The psychiatrist then wrote a new prescription for the antidepressant, entered a note in her chart, and scheduled a follow-up appointment. She noted that AG had an appointment later that day to see the clinic internist who was prescribing the medications for hypertension.

The next day, a different patient with the same name of “AG” arrived at the clinic and asked to see the psychiatrist. She told the receptionist that she had had an appointment at the clinic the previous day, but she had arrived late and then left after she became tired of waiting because her name had not been called. She had now returned to obtain a refill of her antidepressant. The second AG was approximately the same age and was taking the same antihypertensive medications as the AG who had seen the psychiatry resident on the previous day. After reviewing the previous day’s list of clinic appointments with the receptionist, the psychiatry resident realized that the AG seen the previous day had had an appointment with her internist on that day and not with the psychiatry resident.

Discussion

The prescription or administration of an incorrect medication is a common form of medication error1 that is associated with a high risk of serious untoward health consequences.