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Related Experiment Videos

Accidental over-anticoagulation: substitution error by a foreign pharmacy.

S Suwanvecho1, J R Baker

  • 1Department of Internal Medicine, Texas Tech University School of Medicine, Lubbock, USA.

The Annals of Pharmacotherapy
|October 31, 2000
PubMed
Summary

A patient experienced dangerous anticoagulation due to a medication mix-up when obtaining prescriptions internationally. This case highlights risks associated with foreign pharmacies and similar-sounding drug names, emphasizing medication safety.

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Area of Science:

  • Pharmacology
  • Clinical Medicine
  • Patient Safety

Background:

  • Medication errors are a significant cause of patient adverse events.
  • International medication acquisition presents unique safety challenges.
  • Similar-sounding drug names can lead to dangerous substitutions.

Observation:

  • A 57-year-old woman presented with extreme prolongation of prothrombin time and international normalized ratio.
  • The patient had inadvertently taken warfarin (Romesa) instead of ramipril (Ramace) obtained from a Mexican pharmacy.
  • Coagulopathy resolved after administration of fresh frozen plasma and vitamin K, and discontinuation of the incorrect medication.

Findings:

  • Mistaken substitution of warfarin for ramipril resulted in severe, unintended anticoagulation.

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  • The patient had no prior bleeding history, indicating the coagulopathy was solely drug-induced.
  • Visual inspection of medications revealed the critical dispensing error.

    • Implications:

    • Patients seeking medications outside their home country face risks due to differing drug names and potential substitutions.
    • Pharmacists and healthcare providers must be aware of potential international medication errors.
    • Enhanced patient counseling and medication verification are crucial to prevent adverse drug events.