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Volume 27, Issue 1 (Spring 2025) |
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Error in diagnosis and medication prescription in a psychiatric patient with a history of hypothyroidism: A case report
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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 |
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| Keywords: medication errors, methimazole, levothyroxine, hypothyroidism, clinical decision support system |
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Full-Text [PDF 1453 kb]
(30 Downloads)
| Abstract (HTML) (141 Views)
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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
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Extended Abstract: (41 Views) |
Introduction
Medical errors pose a significant challenge to healthcare systems worldwide. According to the World Health Organization, millions of patients each year suffer from medical errors, often resulting in irreversible harm or even death [1]. In 2016, Makary and Daniel from Johns Hopkins University estimated that over 250,000 deaths annually in the United States are linked to medical errors [2]. Among these, diagnostic and medication errors are particularly critical and frequently arise in complex clinical environments, such as inpatient settings.
Thyroid function testing is a commonly performed clinical assessment across various patient populations. However, misinterpretation of these tests—especially in hospitalized or psychiatric patients—can lead to misdiagnosis and inappropriate treatment.
This report reviews a case involving diagnostic and medication errors in a psychiatric patient with a history of hypothyroidism. It serves as a practical example underscoring the importance of coordinated medication management, training in test interpretation, and drug monitoring.
Case Report
A 29-year-old man with a known history of hypothyroidism, treated with levothyroxine, was admitted to a psychiatric facility on November 20, 2023, following a suicide attempt via benzodiazepine overdose and was diagnosed with major depression.
Laboratory tests ordered included liver, kidney, and thyroid function assessments. Results showed elevated alkaline phosphatase (1263 U/L), mildly increased creatinine (1.46 mg/dL), and a TSH level reported within the normal range (2.0 mIU/L).
Due to the abnormal liver and kidney test results, an internist consult was requested. On December 6, 2023, the internist misread the TSH value as 0.2 mIU/L—while the actual number was 2.0, which was within the normal range— interpreting it as abnormally low. This error led to a misdiagnosis of hyperthyroidism, and methimazole 5 mg was prescribed (two tablets every six hours). However, due to methimazole’s unavailability in the hospital pharmacy, the patient did not receive the drug during hospitalization.
When methimazole finally became available on December 9, 2023, it was administered alongside the ongoing levothyroxine treatment. Unfortunately, no repeat thyroid testing was conducted prior to discharge on December 10, 2023. The patient left the hospital with prescriptions for levothyroxine, methimazole, and psychiatric medications.
Error Identification and Response
Following discharge, a routine review of the patient's file by the hospital pharmacy highlighted the simultaneous prescription of levothyroxine and methimazole, raising concerns. The file was referred back to the clinical team, and upon reassessment, the test interpretation error and incorrect medication prescription were confirmed.
The patient was promptly contacted and advised to discontinue methimazole immediately. Subsequently, the Medical Error Review Committee convened to analyze the case thoroughly and develop strategies to prevent similar incidents in the future.
Discussion and Conclusion
This case reveals several critical errors:
1) Diagnostic error due to incorrect test interpretation:
The patient’s TSH of 2.0 mIU/L was within the normal range but was mistakenly read as indicative of hyperthyroidism, resulting in an incorrect diagnosis and inappropriate treatment.
2) Overlooking the patient’s medication history:
The patient was already on levothyroxine for hypothyroidism, and prescribing methimazole without considering this context highlighted poor coordination across treatment teams.
3) Lack of repeat testing:
No follow-up thyroid function tests were performed after methimazole was prescribed and before patient discharge.
4) Failure to manage drug interactions:
Concurrent use of levothyroxine and methimazole is incompatible and could have been prevented with pharmacist oversight or use of smart drug interaction systems.
5) Clinical inaccuracy among healthcare providers:
Errors by the attending physician, psychiatric assistant, and ward nurse during medication administration contributed to the problem.
Supporting this case, a study by Breuker et al. examining unintentional medication inconsistencies and errors in hospitalized patients in France found that 29.4% of patients had at least one medication inconsistency, with the vast majority classified as medication errors. These errors frequently involved medication omissions and were more likely with increased numbers of medications, thyroid diseases, and infectious conditions. The study emphasized that improving medication reconciliation processes and utilizing reliable information sources, such as general practitioners and nurses, can reduce these errors.
Clinical decision support systems (CDSS) have revolutionized healthcare by assisting physicians in complex decision-making tasks since the 1980s. Integrated with electronic health records, CDSS are potent tools to prevent diagnostic and prescribing errors [4, 5]. Additionally, ongoing physician education regarding the interpretation of thyroid tests—particularly in psychiatric and inpatient settings—is vital.
This case exemplifies how diagnostic and therapeutic errors can occur due to misinterpretation of laboratory results, inadequate evaluation of medical history, unrecognized drug interactions, and lapses in clinical oversight. The absence of clinical quality control systems further exacerbated the problem.
Recommendations
To minimize such medical errors, we propose the following measures:
1) Implement CDSS to identify potential drug interactions and guide therapy decisions; 2) Provide continuous physician training on the accurate interpretation of thyroid function tests across varied clinical contexts; 3) Rigorously review existing medications before prescribing new ones; 4) Empower pharmacists in healthcare settings to serve as a final checkpoint for medication orders; 5) Establish systematic error recording and reporting mechanisms to foster learning and quality improvement in healthcare delivery.
Ethical Considerations
This case report was prepared in accordance with ethical standards for the use of patient information. The patient’s identity has been fully anonymized to protect confidentiality. Written informed consent to publish the clinical details was obtained from the patient prior to publication.
All procedures described adhered to the principles outlined in the Declaration of Helsinki, ensuring respect for patient rights and privacy throughout the reporting process.
Funding
There is no funding support.
Authors’ Contribution
Authors contributed equally to the conceptualization and writing of the article. All of the authors approved the content of the manuscript and agreed on all aspects of the work.
Conflict of Interest
Authors declared no conflict of interest.
Acknowledgments
The authors would like to thank the medical and pharmacy staff involved in the patient’s care for their cooperation in providing necessary information. We also appreciate the support of the hospital's Medical Error Review Committee for their efforts in analyzing this case and contributing to improved clinical practices. Finally, we acknowledge the patient’s willingness to share their experience to help enhance patient safety and healthcare quality.
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