A seventyish female called EMS to her house due to a fall and can’t move situation.  The EMS arrived, brought her to the hospital and in doing so gathered up all prescription bottles in a plastic bag.  We refer to this as the Bag’O Meds. The patient was a little obtunded and confused. The nurse in the emergency department dutifully started the medication reconciliation form.  She carefully listed each and every medication, their dose and frequency.  In her zeal to do this, she copied the data for a bottle of the patient’s dog’s medication.  It was for generic Synthroid ® 200 Mcg twice daily.  This bottle had another name on it, it also was a different color with a different colored cap.  It also was clearly marked as coming from a veterinary clinic. We then had perfect storm ensue, instead of correctly marking the drug as twice daily, the nurse put once daily on the sheet. Thus, our pharmacy looked at this, saw it was a high dose, but within normal range so we entered it.  Our hospital gave it to the patient for about two weeks while she recovered.  Finally in the SNF unit  the attending tried to figure out why her heart was racing.  At that point we got the Bag ‘O Meds out and discovered the problem.  If the nurse had entered the correct frequency, the pharmacy and nursing and probably the ER doc would have questioned it.  Needless to say we tapered her off the Synthroid® and she went home to no major clinical problems.

The take home message to everyone is to make sure the Med. Rec sheet is correct and never accept anything at face value.  This is called confirmation bias, and we need to have healthy inquisitive nature when it comes to believing every thing one reads.