Hypoglycemia from a look-alike, sound-alike medication error

Abstract Objective: To describe the effects of a look-alike, sound-alike medication error on the glycemic control and psychiatric well-being of a 23-year-old man. Case Summary: A 23-year-old man presented to the university-based Integrated Multidisciplinary Program of Assertive Community Treatment (IMPACT) team with a diagnosis of schizoaffective disorder, most recent episode manic, and hypertension. The patient was prescribed chlorpromazine 100 mg daily to treat symptoms of psychosis and anxiety. The anxiety, however, persisted and escalated over the following 2 weeks. Upon physical examination of the patient's medications, it was discovered that the patient was inadvertently given chlorpropamide in place of the chlorpromazine. Evaluations, clinical presentation, the medication list, and criteria for an adverse drug event indicated a probable relationship (7 of 12) between the use of chlorpropamide and a hypoglycemic episode. The medication error was noted and corrective actions were taken. Within 1 week...