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April 22, 2021: Safety Bulletin - Sudden Clinical Deterioration: Suspect a Medication Error

ISMP Canada participated in reviewing the unexpected death of an individual who was undergoing rehabilitation in hospital after surgery. More than a week into the hospital stay, the patient began experiencing hypotension, bradycardia, and generalized distress. The patient was transferred to an acute care unit of the same hospital and died later the same day. Initial post-mortem findings suggested that the cause of death was pneumonia; however, the results of toxicology testing, reported several months later, revealed the unexpected presence of verapamil, a medication that had not been prescribed for the patient. Read more ...