A number of years ago I had to hospitalize an elderly female patient for a pleural effusion and “polypharmacy”.

She was taking 17 medications and was followed by four specialists and had no primary care physician. This patient was short of breath, weak and in obvious loss of autonomy. I followed her during her stay at the hospital. After 3 weeks of hospitalization, she was much stronger and her cardio-respiratory status was much improved. She was discharged on 5 medications to be dispensed by dosette. A follow-up appointment was scheduled for the following week.

The discharge script had stated to stop all previous prescriptions and the patient was instructed to fill in the discharge prescription. Our elderly patient, out of convenience, elected to call the pharmacist and have her meds sent in by courier. When I met her again she was not feeling well and had numerous issues which we thought had been resolved during her last admission. When I asked the patient for her list of medications she asked me to check with her pharmacist as she was taking the medication that was dispensed in the dosette. Upon contacting the pharmacist, I realized that the patient was back on her previous drug regimen of 17 meds! I was furious… The pharmacist had no knowledge that the prescriptions were changed as the patient had neglected to notify him. Our elderly patient, upon contacting the pharmacist, was offered a service to home deliver the medication and erroneously thought the pharmacist would know about the changes to her medication.