Table 5.
Characteristics of the serious ME cases reported (Catalonia, 2019–2021).
| Drug | Source of ME | Cause of ME | Additional Pharmaceutical Action | ADR Associated |
|---|---|---|---|---|
| Rocoz® 100 mg (API * Quetiapine) | Pharmacy office | Incorrect dispensing | The two pillboxes causing the error were separated due to similarity in the names of the patients. | Undefined |
| Clopidogrel Normon 75 mg EFG † | Patient’s home | Lack of information and patient non-compliance | The pharmacist urged the family to review the medication with the prescribing physician. | Stroke due to patient non-compliance |
| Augmentine® 500 mg (API * Amoxicillin/clavulanic acid) | Primary care center | Incorrect medical prescription | None | The patient attended the primary care center with chest pain angina and was prescribed Augmentine® 500 mg. Two days later, he returned to the emergency room because he had chest pain. The patient was referred to the hospital, where pericarditis was detected due to an incorrect prescription of the antibiotic dose. |
| Fentanyl® Stada 75 µg EFG † | Patient’s home | Incorrect administration | The patient applied the new patch without removing the old one because he thought the drug had worn off. The pharmacist explained to the patient when and how to remove the fentanyl patch. | Drowsiness, hypotension, and light headedness that resulted in requiring treatment in the primary care center. |
| Furosemide Cinfa 40 mg EFG † | Primary care center | Incorrect medical prescription and system error (structure, process, or organization) | None | The patient had edema in the leg because the doctor forgot to renew the furosemide in the electronic prescription and the patient stopped taking the medication. The patient was hospitalized for ten days. |
| Eliquis® 2.5 mg (API * Apixaban) | Hospital | Incorrect medical prescription | None | The patient was taking acenocoumarol to prevent thromboembolism secondary to a mechanical heart valve. After the change in medication from acenocoumarol to apixaban, the patient suffered another myocardial infarction, with hospitalization and subsequent surgical intervention. |
| Sintrom® 4 mg (API * Acenocoumarol) | Primary care center | Incorrect prescribed dosage and system error (structure, process, or organization) | None | Elevated international normalized ratio (INR) |
| Amoxicillin/clavulanic acid Mylan 500 mg EFG † | Patient’s home | Other causes | Due to the ADR experienced by the patient, the pharmacist advised referring him to the doctor so that he could take it into account in future prescriptions. | After the administration of six doses of antibiotic, the patient stopped the treatment due to the appearance of hemorrhoids. The patient attended the hospital, where she was prescribed a cream for the hemorrhoids. |
| Prednisone Alonga 50 mg EFG † | Primary care center | Incorrect medical prescription and lack of information | The patient was diabetic and suffered facial paralysis. Prednisone 50 mg was prescribed and her basal glycemia rose to 600 mg/dL. The patient was admitted to the hospital and was under observation, where she was administered rapid insulin. The pharmacist advised her to periodically check her glucose levels and take note of when the medication was stopped. | Hyperglycemia |
* API, active pharmaceutical ingredient. † EFG, generic drug.