• Drug dispensing
• medicines reconciliation
• diazepam

An 83-year-old gentleman presented to the emergency department with a 1-month history of increasing lethargy. He had a history of treated hypertension and type II diabetes. His wife had called 999 as he suffered a near syncopal episode at the breakfast table.

Apart from subjective ‘tiredness’, physical examination was unremarkable.

While documenting the notes, a closer inspection of the gentleman's medication packets revealed he had been issued diazepam instead of doxazosin on a repeat prescription a month earlier (figure 1).

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Figure 1

Picture of drug box of Diazepam issued in error.

Drug dispensing errors are a source of avoidable patient morbidity and mortality. When admitting a patient in the emergency department, the aim of medicine reconciliation is to ensure that important medicines are continued and that new medicines are prescribed, with a complete knowledge of what the patient is already taking.1

Recording the drug history from individual drug boxes where available may help detect similar errors in the future.