Too much of a good thing

Medical case study

Background

Mrs H presents to her GP, Dr D, with symptoms suggestive of depression. He decides to treat her with Prozac 20mg daily and issues a prescription for one month. Mrs H feels much better having taken the drug and requests a repeat prescription which is issued by the practice.

She hands the repeat script into her local chemist who notices that the dose has been increased to 60mg. Being a careful pharmacist he telephones the practice to check the dose and is informed that it is correct. So he issues the drug.

After a while Mrs H does not feel so well. So she returns to the practice but this time sees one of the other GPs. She explains to him that she has felt "out of sorts" since taking the higher dose. The GP brings up her record on the computer and checks the repeat prescription: 60mg. So the same prescription is issued again.

After a further month Mrs H returns to the practice still feeling unwell. This time she sees Dr D again. He pulls up her record and when she explains about the dose having been increased he checks and finds that the data in the record refers to a different patient all together. Also Mrs H’s home address is incorrect.

Analysis and outcome

Dr D apologises unreservedly but Mrs H makes a claim for the adverse effects suffered from the Prozac overdosage. The case is judged indefensible and a moderate settlement is negotiated by the MDDUS.

Key points

• Repeat prescriptions need to be accurately recorded on the computer.

• Because it is on a computer does not also mean it is correct.

• Unusual doses or odd changes should be checked against notes or computer records, especially when queried by a pharmacist.

• Names, addresses and dates of birth should also be checked when queries arise.

• People can be "too happy" on medication.