1
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87-year-old man with a.o.t. heart failure with midrange ejection
fraction, chronic atrial fibrillation and orthostatism in medical
history, admitted to hospital (index) because of dizziness, dyspnoea and
chest pain. Unclear aetiology of symptoms (blood pressure 130/70, no
abnormal cardiac biomarker test results, no changes compared with
previous echocardiogram, chest radiograph normal). Ward physician
suspected adverse drug effects due to complex pharmacotherapy and
adjusted treatment: oral furosemide 20 mg once daily, metoprolol 25 mg
once daily and simvastatin 20 mg once daily were stopped, enalapril was
reduced from 10 mg to 5 mg once daily, felodipine 5 mg was started and
an antacid was given during hospital stay. Patient symptoms decreased
and the patient was discharged two days after pharmacotherapy
adjustments. Referral for follow-up was sent to the GP. One and a half
weeks later (before GP follow-up took place), the patient presented at
the ED with dyspnoea and enalapril was increased to 7.5 mg once
daily.
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ED visit
I509 Heart failure
Insufficient or no follow-up (inappropriate treatment)
Hospital
Yes (ward pharmacist cautioned about a relatively large number of
pharmacotherapeutic changes during hospital stay, but no clear
action/follow-up was proposed)
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2
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75-year-old woman with a.o.t. diabetes mellitus type 1, hypertension,
heart failure with preserved ejection fraction (diastolic heart
failure), pulmonary hypertension and paroxysmal atrial fibrillation in
medical history, admitted to hospital (index) because of dyspnoea due to
newly diagnosed COPD stage 2. COPD exacerbation was treated with 5-day
course of amoxicillin and prednisolone, and the patient was prescribed
tiotropium and terbutaline inhalers upon discharge. Previous treatment
with carvedilol (non-selective beta-blocker) 25 mg twice daily for heart
failure was continued. Three days later, the patient was readmitted due
to worsening dyspnoea. Patient had not been taking the inhalers, because
no inhalation instruction had been provided. During readmission, the
patient received inhaler training and carvedilol was replaced with
bisoprolol (selective beta-blocker).
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Readmission
J441 COPD with acute exacerbation
Non-compliance (inappropriate treatment)
Hospital
Yes (ward pharmacist tested patient’s inhalation technique and
recommended prescribing specific inhalers during hospital stay, but
there was a lack of medication reconciliation and inhaler instructions
upon discharge)
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3
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88-year-old woman with a.o.t. diastolic heart failure and chronic atrial
fibrillation, admitted to hospital (index) because of dyspnoea and lower
back pain due to pneumonia and lung oedema and collapsed vertebra due to
osteoporosis, respectively. During hospital stay,
enalapril/hydrochlorothiazide 20/12.5 mg was replaced by losartan 50 mg
once daily because of high age and dry cough (adverse drug effect of
enalapril). Oral furosemide 40 mg once daily was started, but the
patient developed hypokalaemia and received potassium supplementation
during hospital stay. Previously prescribed bisoprolol 10 mg and
felodipine 5 mg once daily were continued. Patient discharged to nursing
home with referral to GP for follow-up. After two weeks, hospital
readmission due to dyspnoea and tachycardia (heart rate 130–160
beats/minute) with normokalaemia. Bisoprolol dosage was increased to 15
mg once daily and felodipine was stopped. Furosemide was increased to 40
mg in the morning and at noon.
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Readmission
I489 Atrial fibrillation
Inadequate treatment (insufficient or no follow-up, inappropriate
treatment)
Hospital
Not applicable (no MR, control group)
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4
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69-year-old man with a.o.t. persistent atrial fibrillation in medical
history, admitted to hospital (index) because of diarrhoea, vomiting and
iron deficiency anaemia, probably due to gastrointestinal bleeding (no
clear source of bleeding identified through gastroscopy and
colonoscopy). Apixaban was temporarily paused and replaced with
dalteparin awaiting capsule endoscopy. During 6-week post-discharge
follow-up, the physician and patient discussed the potential restart of
apixaban if haemoglobin levels are recovered and stabilised, followed by
close monitoring of haemoglobin. Two weeks later, no identification of
bleeding source through capsule endoscopy, although some parts of the
endoscopy results were unclear. Follow-up visit planned by hospital, but
did not take place (reason unclear) and no reminder to patient. Three
months later, readmission with iron deficiency anaemia. Patient had
switched back from dalteparin to apixaban on his own initiative, having
misunderstood the physician as stating that apixaban could be
restarted.
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Readmission
K922 Gastrointestinal haemorrhage
Non-compliance (insufficient or no follow-up)
Hospital
Not applicable (no MR, control group)
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5
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69-year-old man with a.o.t. dysuria with haematuria due to suspected
thickening of bladder wall and enlarged prostate in medical history,
admitted to hospital (index) because of fever and weakness due to
endocarditis. Decrease in renal function (eGFR from 58 to 31 ml/min/1.73
m2) during hospital stay, probably due to antibiotic
treatment. Discharged to nursing home with antibiotic treatment adapted
to renal function and follow-up by hospital. Ten months later, the
patient presented to GP with sleep problems, nocturia, constipation and
an ‘unpleasant feeling in the stomach’. GP prescribed mirtazapine 15 mg
once daily in the evening and hyoscyamine sulphate (anticholinergic) 0.4
mg twice daily without any lab tests or notes regarding previous renal
and urinary problems. Three days later, the patient presented at the ED
with acute urinary retention for which he received a urinary
catheter.
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ED visit
R33 Retention of urine
Inappropriate treatment
Primary care
No (cause originated after MR)
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