Lack of pharmacist-physician communication associated with nimesulide-induced oligohydramnios during pregnancy

The consequences of medication errors can be serious, especially in pregnant women. When decision-making is critical, physician-pharmacist communication has the potential to improve patient safety. In this report, we describe the case of a pregnant woman who developed oligohydramnios after taking nimesulide for neuropathic pain. The drug was improperly prescribed by a family physician and mistakenly dispensed by a community pharmacist. Oligohydramnios was observed during ultrasound examination and an iatrogenic cause was suspected. This case is presented to raise awareness that patient safety is threatened because of a lack of physician-pharmacist communication, especially for pregnant patients.

Healthcare professionals are continually at-risk for making errors at work. Effective inter-professional communication should be an organisational tool to prevent adverse events for pregnant women.