Out of sight: a lesson in drug errors

Abstract

A 76-year-old man developed recurrent encephalopathy, visual disturbance, myoclonus, generalised seizures and atonic drop attacks on a background of a gastrectomy for adenocarcinoma and stable chronic lymphocytic leukaemia. He presented to three different hospitals and was admitted twice, with normal investigations. His symptoms transiently improved during each admission (and with starting levetiracetam) but recurred each time on hospital discharge. Subsequent careful inspection of his medication box identified that his community pharmacy had in error been dispensing baclofen 80 mg per day instead of his prescribed Buscopan 80 mg per day. This case highlights the importance of physically inspecting a patient’s medications and emphasises the spectrum of baclofen-related toxicity; it also highlights potential deficiencies in the pharmacy dispensary process and the need for multiple checks by patients and professionals.

Optimization for medical logistics robot based on model of traveling salesman problems and vehicle routing problems

“…16,17 Drug circulation in pharmacy is a key link of modern pharmaceutical logistics that lead to medical logistic robots developed for reducing dispensing errors, including comparability misses of drugs' name and dispensing dysfunction, which occur at this stage may harm the patient directly. 18,19 A medical logistics robot, named as fast medicine dispensing system (FMDS), is designed to administer medicines and make up electronic prescriptions automatically to replace manual work as required before. 7,20 In many Asian countries, physicians play a dual role in checking prescription and dispensing medicine, and they have essentially no time to instruct patients in terms of drug usage.…”