577 results for “medication monitoring”
81y · Female·Subdural haemorrhage from fall with exacerbation by anticoagulant therapy
… management with repeat imaging. However, when discharged to nursing home respite care on 23 December, a medication administration error occurred: rivaroxaban was continued from 24-28 December despite the hospital discha…
54y · Female·Complications of mixed drug toxicity (opiates, zolpidem, benzodiazepines and dox…
…xed drug toxicity (opiates, zolpidem, benzodiazepines, doxylamine). She had been accumulating prescribed medications over extended periods despite her brother's concerns about out-of-date medicines. Letters found at the …
37y · Male·cardiac arrhythmia
…37-year-old man died in custody from cardiac arrhythmia, with morbid obesity and concurrent psychotropic medications carrying QT-prolongation risk identified as contributing factors. Key clinical lessons include: (1) pol…
24y · Male·Combined drug toxicity (clonazepam, diazepam, methadone, tramadol, pregabalin)
…wing a motor vehicle collision in 2020, he developed opioid addiction and engaged in doctor-shopping and medication-sharing with his partner without his GP's knowledge. His GP prescribed tramadol, pregabalin, clonazepam,…
54y · Male·Unable to be ascertained. Multiple contributing factors identified: arrhythmogen…
…tient overdosed significantly); physiological stress from psychosis and physical restraint; and possible medication miscommunication. Critical clinical lessons: (1) the combination of doxepin and venlafaxine requires car…
49y · Male·hanging
…tally unsuitable for managing his complex, enduring illness. The decision to permit unsupervised monthly medication dispensing in December 2015 and March 2017 was made without involvement of his treating psychiatrist and…
84y · Female·Major cerebral infarct due to hypoglycaemia
…nd bilateral cerebral infarcts. After 8 units of Actrapid insulin at 21:15, no blood glucose level (BGL) monitoring was documented until 5:05 am the next morning when she was found unresponsive with a BGL of 0.8 mmol/L. …
19y · Female·combined drug effect and myocarditis
… hours, she was sedated and transferred via Royal Flying Doctor Service from Broome to Perth. A critical medication error occurred: nursing staff prepared a syringe containing 200mg/40ml of haloperidol instead of the int…
37y · Male·mixed drug toxicity
… mixed drug toxicity. Over four months, he obtained prescriptions from 19 different doctors for multiple medications including opioids and benzodiazepines. His brother observed signs of intoxication and removed accessibl…
Unknown·Deaths from injuries sustained in a mass stabbing attack
…l 2024. The perpetrator, Joel Cauchi, had treatment-resistant schizophrenia and had ceased antipsychotic medication. Key clinical findings identified serious deficiencies in psychiatric care, including inadequate managem…
25y · Male·Sudden Unexpected Death in Epilepsy (SUDEP)
…ose due to a court video link. During imprisonment, Dr L. provided appropriate medical care with regular monitoring and dose adjustments; blood tests showed therapeutic medication levels (6.9 mg/kg) and seizure frequency…
44y · Male·Positional asphyxia
…ng to death in an awkward position on a couch with his neck sharply flexed. Key clinical lessons: unsafe medication handling and sharing of controlled antipsychotics poses serious risk; combination of alcohol with clozap…
49y · Male·Unascertained - cardiac arrhythmia with terminal aspiration in an overweight man…
…nthixol acetate (Acuphase). After transfer to Bentley that afternoon, critical information was lost: the medication chart did not record Acuphase administration, and the admitting doctor failed to recognize from availabl…
34y · Female·Mixed drug toxicity
…ful prescribing management by her GPs using weekly reviews, restricted pharmacy pickups and prescription monitoring, she obtained pregabalin from multiple doctors and used diverted medications. On 6 July, Dr V. appropria…
42y · Female·Multiple stab wounds
…after acute onset of paranoid delusions. She was commenced on risperidone but showed poor engagement and medication compliance. Between December 2020 and January 2021, clinical review was predominantly conducted via brie…
52y · Male·Mixed drug toxicity
… fentanyl prescriptions only 6 days apart. Clinical lessons include: implementing real-time prescription monitoring for all drugs including pregabalin; coordinating prescribing across multiple clinicians; recognising med…
38y · Male·Multidrug toxicity
…received buprenorphine for opioid withdrawal management alongside benzodiazepines and other psychotropic medications. Critical clinical errors occurred: nursing staff observed pinpoint pupils indicating opioid intoxicati…
13y · Male·Asthma
…cians lacked real-time access to PBS dispensing data showing Master S was collecting far fewer preventer medications than prescribed, suggesting poor medication adherence. Had clinicians known this objectively, they coul…
27y · Male·hanging
…08 and managed by an outpatient team. The coroner found his care hindered by poor engagement and reduced monitoring. Although Mr Alieff received his depot medication regularly and showed no symptoms of relapse at his las…
24y · Male·multiple stab wounds to the chest that he inflicted upon himself
…ehicle theft, assault, and police pursuit. Despite psychiatric treatment with antipsychotics, he stopped medication multiple times. On 4 January 2019, he rammed a police vehicle, stole a truck and taxi, stabbed a member …
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