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:: Volume 27, Issue 1 (3-2025) ::
EBNESINA 2025, 27(1): 119-125 Back to browse issues page
Error in diagnosis and medication prescription in a psychiatric patient with a history of hypothyroidism: A case report
Azam Sharifi Rizi , Vahid Donyavi * , Parya Hajgholamrezaee
Department of Psychiatry, Faculty of Medicine, Aja University of Medical Sciences, Tehran, Iran , v.donyavi@ajaums.ac.ir
Abstract:   (256 Views)
This article reports a case of a medical error in the diagnosis and treatment of thyroid disease in a 29-year-old man hospitalized following a suicide attempt and diagnosed with severe depression. The patient had a history of hypothyroidism managed with levothyroxine. During his hospitalization, abnormal liver and kidney test results prompted an internal medicine consultation for further evaluation. The specialist mistakenly interpreted the patient’s TSH level as 0.2 mIU/L (instead of 2.0), diagnosed hyperthyroidism, and prescribed methimazole. Although the drug was not available in the hospital pharmacy, the patient received methimazole the day before discharge, which he took concurrently with levothyroxine. Upon review of the patient’s file, the ward pharmacist identified this drug interaction and contacted the patient to discontinue methimazole. This case clearly illustrates diagnostic and therapeutic errors caused by incorrect test interpretation, poor coordination in medication management, and insufficient clinical supervision. The study explores the possible causes of these errors, emphasizes the importance of clinical decision support systems, highlights the need for ongoing staff training in thyroid test interpretation, and underscores the crucial role of pharmacists in preventing medication errors.
Keywords: medication errors, methimazole, levothyroxine, hypothyroidism, clinical decision support system
Full-Text [PDF 1453 kb]   (77 Downloads) |   |   Extended Abstract (HTML)  (88 Views)  
Type of Study: Letter to Editor | Subject: Military Psychiatry
Received: 2024/02/26 | Revised: 2025/05/15 | Accepted: 2025/05/28 | Published: 2025/06/6
References
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3. Breuker C, Macioce V, Mura T, Castet-Nicolas A, Audurier Y, Boegner C, et al. Medication errors at hospital admission and discharge: Risk Factors and impact of medication reconciliation process to improve healthcare. Journal of Patient Safety. 2021;17(7):e645-e652. doi:10.1097/pts.0000000000000420
4. Sutton RT, Pincock D, Baumgart DC, Sadowski DC, Fedorak RN, Kroeker KI. An overview of clinical decision support systems: benefits, risks, and strategies for success. Nature Partner Journals Digital Medicine. 2020;3:17. doi:10.1038/s41746-020-0221-y
5. Standiford TC, Farlow JL, Brenner MJ, Conte ML, Terrell JE. Clinical Decision Support Systems in Otolaryngology-Head and Neck Surgery: A State of the Art Review. Otolaryngology-Head And Neck Surgery. 2022;166(1):35-47. doi:10.1177/01945998211004529
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Sharifi Rizi A, Donyavi V, Hajgholamrezaee P. Error in diagnosis and medication prescription in a psychiatric patient with a history of hypothyroidism: A case report. EBNESINA 2025; 27 (1) :119-125
URL: http://ebnesina.ajaums.ac.ir/article-1-1334-en.html
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Volume 27, Issue 1 (3-2025) Back to browse issues page
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