Mrs X.X. Born 1941 Known severe Rheumatoid arthritis Revision of hip replacement Jan Cardiac arrest post-op Anticoagulated Transferred to community hospital mid Feb INR increasing to 7.5

Hb 8.5 Wound oozing Readmitted to BRI late Feb. INR 9.3 Drugs: warfarin, methotrexate, coproxamol,lactulose, paroxetine, calcichew, atenolol, hydroxychloroquine, tibolone, thyroxine, amitriptyline, folate Urea 11.1 Albumin 26

What is the possible explanation for the loss of control of the anticoagulant?

Mrs Y.Y. Born 1912 Admitted late Feb with general deterioration in health, nausea, anorexia, constipation At her EPH there had been an outbreak of D+V 4 weeks previous. She had never really got better. Dehydrated, hypotensive, pale, slow reg pulse

Drugs – perindopril, digoxin, frusemide, aspirin, Isosorbide mononitrate Urea 31, creatinine 223 ECG ……………

Digoxin level 3.5 What went wrong?

Recent Scenario 62 year old man known epileptic admitted with worsening angina received angioplasty Sept On Isosorbide, aspirin, amlodipine, GTN, carbamazepine and primidone. Recorded in admission note that patient had previously been intolerant of diltiazem. Cardiology SpR discontinued amlodipine and started diltiazem. Patient transferred to general ward. 5 days later becomes ill – off his food and drowsy. Any ideas?

Discharged following recovery at the weekend. Readmitted 2 weeks later (Oct 1999) with seizures. Carbamazepine had been stopped 3 days earlier by GP because of high carbamazepine level and patient’s complaint of nausea. Any more ideas? December 2001 UBHT receive letter from solicitors alleging negligence.

Mrs Mary Lamb aged 76 presented 6 weeks ago to her GP having noticed a lump in her right breast. She was seen by the surgeon urgently who confirmed to her that there was a possibility that the lump was malignant. She had been seen 2 weeks ago at the pre - operative assessment clinic when unfortunately her blood pressure was found to be high and she had been advised that surgery might need to be delayed until her GP had got her blood pressure under control. Mrs Lamb requested an urgent consultation with the GP and was started on atenolol 100 mg daily to reduce her blood pressure and her high pulse rate. She collects the prescription from the pharmacy and takes the tablets as prescribed. She was soon admitted for surgery. The house surgeon recorded her blood pressure on admission at 210 / 105 and this was confirmed in the overnight nursing observation charts. She proceeded to mastectomy the next day.

At the drug ward round one week later the nurse is uncertain about giving the atenolol, “Stemetil” and diltiazem all of which are prescribed, having noticed that the blood pressure is 93 / 55 and has been so for the last few days. The patient feels tired but otherwise is well. She considers asking the advice of the pharmacist. The pharmacist happens to be on the ward and she agrees that the House Surgeon should make a decision before the dug is given. The house surgeon is called and she is also uncertain and decides to consult further. What are the issues raised in this case which illustrate the responsibilities of each of the three professions in ensuring the safe treatment of this patient?

) A skinny 30 year old lady is admitted 12 hours after an apparent overdose of paracetamol. Her plasma paracetamol level is 50 mg/1 (just below the usual treatment line). No antidote is given. Eight hours later her level of consciousness falls. What are the possible reasons?

A 78 year old lady is admitted from her lonely dilapidated flat having been found on the floor. The neighbour has brought in her medication bottles labelled - "Inderetic", loprazolam, digoxin, "Ponstan", imipramine, "Mysoline". She remains drowsy and then has a series of major seizures. What are the possible reasons?