July â¢ August 2005 - Ontario College of Pharmacists

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CORONER’S REPORT CORONER’S REPORT Although the cause of death was not absolutely determined in the following case, pharmacists can play an important role in collaborating with physicians, especially in the case where patients with complex needs are on drugs with a narrow therapeutic range. Case The case of a 22-year-old woman who suffered from an eating disorder and a major affective disorder raises the need for coordinated care and careful attention to potential adverse effects of prescribed medication. An Ontario coroner recently investigated the sudden death of a 22-year-old woman who was discovered at home. She had a protracted history of a complex eating disorder characterized by purging. Different physicians had treated her at a number of health care facilities in the United States and Canada. At the time of the death, the coroner was unable to clearly discern whether a single physician was coordinating care. There was evidence that the many health care providers involved did not have the ready ability to share their records electronically, which may have exacerbated any discoordination of care. Hypokalemia had been a recurring consequence of the eating disorder. The serum potassium varied between 2.9 to 4.9mM/L in the tests reported to the coroner in the year prior to the death. All EKGs had been normal with no evidence of conduction abnormality, tachydysrhythmia or pre-excitation. Twelve days prior to death, her serum potassium was 3.2mM/L. The deceased had been treated by psychiatrists and had been most recently diagnosed as suffering from bipolar affective disorder. Though one of the psychiatric consultants involved had advised against the use of lithium in the presence of hypokalemia, this medication was being prescribed at the time of death (increased to 1200 mg/day just prior to death). Other medications were Lamotrigine (though the patient was likely non-compliant with this medication), Slow K (two tablets BID PO) and an oral contraceptive. An autopsy ordered by the coroner did not reveal an anatomic cause of death. Toxicologic analyses revealed the lithium level to be 0.31mM/L (therapeutic range 0.5 - 1.2mM/L) with no other toxic agents or drugs. Based on the foregoing, it was not possible to precisely determine the cause or manner of death. It is possible that the combination of mild hypokalemia and Lithium was implicated but this cannot be proven. A PubMed search identified only a single case report of hypokalemiaassociated cardiac toxicity during lithium administration. It is, however, likely that there is under-reporting of such adverse medication events. Recommendations Arising from Coroner’s Investigation: 1. When managing patients with complex medical problems, it is important that one physician is always identified as the “medical quarterback”. 2. Health care providers and government should continue to pursue development of methods to improve sharing of medical information e.g. secure Web-based electronic medical records. Adverse drug effects (including potential events) should consistently be reported by physicians and coroners to Health Canada, particularly in the case of uncommon adverse events. Note to Pharmacists: Pharmacists are reminded to be especially alert for complex patients on Lithium because of the drug’s narrow therapeutic range. Pharmacists should always counsel about adequate fluid intake and should be aware of other complications which might affect the electrolyte balance. Collaborating with the prescribing physicians is also key as it could provide you with missing pieces of information that can make a difference in patient care, especially when more than one physician is involved in treating the patient. 38 Pharmacy Connection July • August 2005
SUMMARY OF LAWS The Summary of Laws table, on pages 40 and 41, summarizes the Federal and Provincial Laws Governing Prescription Drug Ordering, Records, Prescription Requirements and Refills. (Revised May 2005) Please copy and post this reference tool in your pharmacy. For your convenience, this document is downloadable from our website in PDF format. Notes: • This is a summary. For complete details refer to the official legislation • Prescriptions must be filed in sequence as to date and number • Prescriptions must be retained for not less than two years • Narcotic and controlled drugs, and targeted substances may only be ordered by a pharmacist so designated by the designated manager or authorized person at a hospital • Drug names used are for illustrative purposes only. This is not a complete list • Legislation can change. Keep abreast of changes in prescription requirements Pharmacy Connection July • August 2005 39
Page 1 and 2: July/August 2005
Page 3 and 4: contents Ontario College of Pharmac
Page 5 and 6: Council Elections NEW PUBLIC MEMBER
Page 7 and 8: many steps in the process undertake
Page 9 and 10: Point of Care Leslie Braden, R.Ph.,
Page 11 and 12: Television Commercial Members stron
Page 13 and 14: Medication Awareness We have tracke
Page 15 and 16: Awareness of College and Its Role a
Page 17 and 18: Position Available: Pharmacy Inspec
Page 19 and 20: MINISTRY OF HEALTH NOTICE EMERGENCY
Page 21 and 22: this Act and the regulations made u
Page 23 and 24: Toronto Central Toronto Central Cen
Page 25 and 26: HEALTH CANADA Advisories & Notices
Page 27 and 28: What you told us The LP, in its pre
Page 29 and 30: The Ontario Health Pandemic Influen
Page 31 and 32: CLOSE-UP ON COMPLAINTS PREVENTING D
Page 33 and 34: However, in the event that the memb
Page 35 and 36: ISMP List of Error-Prone Abbreviati
Page 37: HCl hydrochloric acid or hydrochlor
Page 41 and 42: Summary of Federal and Provincial L
Page 43 and 44: Pharmacists suspended for non-payme
Page 45 and 46: F O C U S O N Error Prevention CASE
Page 47 and 48: O C P M A N U A L - August 2005 Eac

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July â¢ August 2005 - Ontario College of Pharmacists