The Risks of Reflexive Refilling

The electronic health record and electronic prescribing have transformed the practice of medicine. Both have led to improved efficacy and safety in medication management. However, dangers may arise when electronic prescription requests are filled by default and when electronic health record medication lists are presumed accurate. In this case, our patient underwent 2 days of inpatient evaluation before a thorough medication reconciliation revealed that his symptoms had likely resulted from a medication that had been refilled reflexively.

A 69-year-old man presented with worsening weakness, weight loss, decreased appetite, and nonbloody diarrhea. Imaging revealed a large right pleural effusion and a nonspecific colitis. Lab workup revealed significant bicytopenia, hypogammaglobulinemia, and hypolipidemia. Initial evaluation and diagnoses were focused toward causes of malnutrition and malabsorption. However, on hospital day 2, a pharmacist discovered that the patient had been taking long-term oral linezolid for unclear reasons. With cessation of linezolid, the patient's myriad symptoms resolved and all lab values progressively normalized.

The side effects of linezolid have been well documented and include reversible myelosuppression and gastrointestinal symptoms. However, medication reconciliation was imperative in diagnosing and treating our patient. Further, reflexive refilling of this patient's medication likely explains why he was taking linezolid for such a long period of time, as other forms of automation bias are known to introduce errors in electronic prescribing.

This case calls attention to the importance of medication reconciliation, the danger of overreliance on electronic health record medication lists, and the pitfalls in not maintaining vigilance with electronic prescribing. It also highlights the necessity of patient and caregiver education regarding their medications.