Correct Diagnosis, Wrong Medication, Unusual Adverse Event

Abstract

Case study: A 37 year old woman with a history of migraines presented to an urgent care center with an atypical headache. She had awakened with the headache, an uncommon occurrence for her. Although severe, the headache was different in character compared with her usual migraine headaches and was unrelieved by her usual migraine medication. Careful investigation revealed that she had used permethrin, applying it her skin from neck to feet prior to going to bed the previous night. The patient had consulted a family nurse practitioner (FNP), at her place of employment, for an “ugly” rash. The FNP had correctly diagnosed the rash as astineacorporis but prescribed treatment indicated for scabies. The patient’s headache was successfully treated with Toradol and intravenous fluid bolus. Permethrin: Permethrin is a neurotoxin, used extensively as a pesticide and insect repellent. It is classified as a restricted use pesticide (RUP) by the Environmental Protection Agency (EPA) due to its toxic effects on aquatic life and beneficial insects, such as honey bees [1]. Although little is known about its neurotoxicity in humans [2], permethrin is first line treatment for scabies, considered safe for infants as young as two months old [3]. Systemic adverse events are reportedly rare, but do include headache [4]. Discussion: Adverse drug events (ADEs) resulting from errors, considered preventable ADEs, are associated with unacceptable costs to the US healthcare system, in addition to inordinate pain and suffering [5]. A preventable (ADE) resulting from the wrong medication being prescribed for a correctly diagnosed condition could potentially be avoided by the inclusion of a diagnoses on medication prescriptions. Error checks built into software systems could alert practitioners and/or pharmacists of a mismatch between medication and indication. Further research is needed to investigate the feasibility and value of potential interventions for reducing preventable ADEs.