Angry Patient OSCE - Medication Error Complaint

Diagnosis: Medication Error Complaint

Case Overview

  • Age/Sex: 48-year-old male
  • Occupation: Office-based IT worker (sedentary)
  • Setting: Primary care clinic / outpatient visit after pharmacy issue
  • Chief complaint: "I want to make a complaint — I was given the wrong medicine and I'm feeling awful."

Patient Script

Who I Am

I'm a 48-year-old IT guy who sits at a desk all day and drives to work.

What Brings Me In

I came because I was given the wrong medicine at the pharmacy three days ago and I want to complain — I'm still feeling unwell and worried it might have harmed me.

My Story

A week ago my GP told me I should start a medicine for my cholesterol. I went to the pharmacy the same day and started taking the new tablets that night. About three nights ago I noticed I was very sleepy during the day, had a very dry mouth, and was constipated. On Tuesday I nearly dozed off while driving and that scared me. I also felt a bit dizzy when I stood up once yesterday. I looked at the pill bottle and it says a different drug than what the GP said. I kept taking it for three days because I thought it was the right one, but now I'm angry and want someone to explain and sort it out.

My Medical Background

  • Past medical history: Hypertension diagnosed 2 years ago; no known depression
  • Current medications: Lisinopril 10 mg once daily; occasional ibuprofen for backache
  • Recent medication change: GP told me to start a cholesterol tablet this visit (no prior statin)
  • Allergies: Penicillin — rash as a child
  • Social: Smokes about 15 cigarettes/day; drinks alcohol socially (had a few beers last weekend)
  • Family: Father had a heart attack at 60; mother alive with type 2 diabetes

What I Think & Worry About

  • I think the pharmacy gave me the wrong drug and that’s why I feel awful.
  • I worry that I’ve damaged my health by taking the wrong pills and that no one will take me seriously.
  • I want an apology and I want whoever is responsible to fix this and make sure it doesn’t happen to someone else.

If You Ask Me About Other Symptoms...

  • Chest pain: "I felt a twinge of discomfort once while stressed, but it was short and went away — not like crushing chest pain."
  • Shortness of breath: "No, I can breathe fine."
  • Palpitations: "I felt my heart racing a couple of times when I was dizzy, but it settled down."
  • Headache / visual changes: "My vision seemed a bit blurred at night and lights looked fuzzy."
  • Bowel / urine: "I've been constipated since starting the tablets and my mouth has been very dry."
  • Mood / sleep: "I'm more sleepy during the day; I actually have trouble concentrating at work now."
  • What I took tonight: "I stopped taking the new tablets last night after I saw the label and felt worse. I still take my lisinopril in the morning."

Clinical Summary

Examination

  • General: alert but mildly drowsy, cooperative
  • Vital signs: BP 110/72 mmHg, HR 102 bpm (regular), RR 14/min, SpO2 98% on air, Temp 36.8°C
  • CVS: heart sounds normal, no murmurs; peripheral perfusion adequate
  • Respiratory: chest clear to auscultation
  • Abdomen: soft, mild distension, decreased bowel sounds
  • Neurological: pupils mildly dilated and reactive; no focal deficit; mildly slowed cognition/processing
  • Mucous membranes: noticeably dry

Investigations

  • ECG: sinus tachycardia 100–105 bpm (no ischemic changes)
  • Obs bloods: CBC: Hb 15.0 g/dL, WCC 7.5 x10^9/L, Platelets 220 x10^9/L (within reference)
  • U&E: Na 140 mmol/L, K 4.0 mmol/L, Creatinine 88 µmol/L (eGFR >60) (normal)
  • LFTs: AST 24 U/L, ALT 28 U/L (normal)
  • Blood glucose: 5.6 mmol/L (normal)
  • Medication reconciliation: Prescription from GP: "Atorvastatin 20 mg nocte"; dispensed bottle label: "Amitriptyline 25 mg, 1 tablet at night" (patient was given this and took for 3 nights)
  • Pharmacy contact: confirmed dispensing error due to packaging/name mix-up (pending formal report)

Diagnosis

  • Primary diagnosis: Medication dispensing error — patient was dispensed and ingested amitriptyline 25 mg nightly instead of intended atorvastatin 20 mg, causing anticholinergic effects and sedation.

    • Evidence: temporal relationship (symptoms started within 24–72 hours of starting the new tablets), anticholinergic features (dry mouth, constipation, blurred vision, mydriasis, drowsiness), pill bottle label documenting the wrong drug, and patient report of recent pharmacy dispensing.

  • Differentials:

    • Adverse effect from another substance (alcohol or OTC sleep aid): less likely because symptoms began after starting the new labelled tablet and patient denies new OTC meds apart from the tablet; alcohol intake was social and not excessive recently.
    • Acute cardiac event (e.g., arrhythmia/ischemia): less likely — ECG shows sinus tachycardia without ischemia, vitals stable, no ischemic chest pain history or troponin elevation (troponin not elevated/pending if done).
    • Primary psychiatric disorder (new depression/antidepressant initiation): unlikely given no prior psychiatric symptoms and the patient reports no prior depression; also the medication taken was not prescribed for mood.

Management

  • Immediate actions:

    • Stop the incorrect medication (patient has already withheld further doses since last night).
    • Assess and monitor for deterioration: observe vitals, mental status, and cardiorespiratory status; arrange supervised observation if drowsiness worsens or breathing/cardiac instability occurs.
    • Manage symptoms supportively: ensure hydration, treat constipation (laxative), advise no driving/work while drowsy.
    • If severe anticholinergic toxicity (agitation, severe tachycardia, hyperthermia, seizures, coma) — liaise with emergency/acute medicine; specialist consideration for physostigmine (only in severe cases under specialist guidance).

  • Investigation/confirmation and medication safety:

    • Obtain and keep the dispensed medication and label as evidence; photograph packaging if needed.
    • Contact the dispensing pharmacy immediately to confirm details and request incident report; ask for batch/lot and staffing information if relevant.
    • Notify the prescribing GP and pharmacy; document event in the medical record; inform patient of plan and offer written information.
    • Report the incident through local patient safety/incident reporting system and advise pharmacy to initiate internal review.

  • Ongoing care and communication:

    • Apologize and explain to the patient what likely happened and what will be done to investigate and prevent recurrence; offer to help with a formal complaint process.
    • Reconcile medications and, after discussion with patient and GP, consider re-prescribing atorvastatin if still indicated once patient understands risks/benefits.
    • Arrange short-term follow-up (24–72 hours) to ensure resolution of anticholinergic symptoms and to assess any delayed effects.
    • If any suspicion of harm beyond mild effects (e.g., injury in a near-miss driving event), consider further documentation and advice regarding driving and employment safety.

Key Learning Points

  • Always consider medication error when new symptoms start soon after a prescription change; perform medication reconciliation and inspect pill bottles/labels.

  • Early open disclosure, prompt assessment of harm, and reporting/documentation are essential parts of managing suspected medication errors.

  • Management is primarily supportive for mild–moderate anticholinergic toxicity; severe toxicity requires specialist input and specific antidotes under guidance.

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