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Related Experiment Videos

Dispensing error causing fatal chlorpropamide intoxication in a nondiabetic.

D M Scala-Barnett, E R Donoghue

    Journal of Forensic Sciences
    |January 1, 1986
    PubMed
    Summary

    A pharmacy dispensing error led to a fatal hypoglycemia case when chlorpropamide (Diabinese) was mistakenly given instead of acetaminophen with codeine. This highlights the critical need to verify medication labels and contents in unexpected adverse drug events.

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    Area of Science:

    • Pharmacology
    • Clinical Toxicology
    • Patient Safety

    Background:

    • Pharmacy dispensing errors can lead to severe adverse drug events.
    • Accurate medication identification is crucial for patient safety.

    Observation:

    • A 38-year-old nondiabetic female experienced fatal hypoglycemia.
    • The patient received chlorpropamide (Diabinese) instead of acetaminophen (Tylenol) with codeine due to a dispensing error.
    • Initial serum glucose was < 20 mg/dL, with a serum chlorpropamide level of 124 µg/mL upon admission.

    Findings:

    • Accidental substitution of chlorpropamide for acetaminophen with codeine resulted in severe hypoglycemia.
    • High serum chlorpropamide levels confirmed the overdose and causative agent.

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    Implications:

    • Unexpected drug effects necessitate a thorough investigation of potential dispensing errors.
    • Verification of medication labels and contents is vital in suspected drug overdose cases.
    • This case underscores the importance of stringent pharmacy quality control measures to prevent medication errors.