Rhabdomyolysis in a woman with multiple myeloma and renal impairment
AI-generated summary
Margaret Ann Yeomans, aged 79, died from rhabdomyolysis in the context of multiple myeloma and chronic renal impairment. A critical medication error occurred when rosuvastatin 40mg was dispensed instead of her prescribed simvastatin 40mg on 27 June 2016. The pharmacist's final check failed to identify the error, and when the patient's husband raised concerns about the different medication appearance, staff reassurance prevented correction. Mrs Yeomans consumed the incorrect high-dose statin for weeks before hospital admission with acute renal failure. The coroner found the dispensing error and pharmacist's failed verification were contributing factors to her death. Clinical lessons include: rosuvastatin carries higher myopathy risk than simvastatin at high doses in elderly patients with renal impairment; pharmacy verification systems must not be bypassed by reassurance without proper checking; and patient/family concerns about medication appearance should trigger immediate pharmacist review rather than dismissal.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Dispensing of incorrect statin (rosuvastatin instead of simvastatin) at high dose
Pharmacist's failure to verify medication during final check
Staff reassurance without proper verification when patient's husband raised concerns about medication appearance
Pre-existing chronic renal impairment
Pre-existing multiple myeloma
Advanced age
Controlled hypothyroidism
Respiratory compromise secondary to fluid overload
Urinary tract infection acquired in hospital
Coroner's recommendations
The Epping Plaza Chemmart should institute a policy whereby concerns about dispensed medication raised by customers are referred to the pharmacist for review
The National Council of the Pharmacy Guild of Australia should review the circumstances of Mrs Yeomans' death for purposes of education, awareness and creation of robust dispensing policies and guidelines
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