TY - JOUR T1 - Out of sight: a lesson in drug errors JF - Practical Neurology JO - Pract Neurol SP - 243 LP - 245 DO - 10.1136/practneurol-2019-002301 VL - 20 IS - 3 AU - Soon Tjin Lim AU - Timothy Yates AU - Di Liang AU - Heather Angus-Leppan Y1 - 2020/05/01 UR - http://pn.bmj.com/content/20/3/243.abstract N2 - A 76-year-old man developed recurrent encephalopathy, visual disturbance, myoclonus, generalised seizures and atonic drop attacks on a background of a gastrectomy for adenocarcinoma and stable chronic lymphocytic leukaemia. He presented to three different hospitals and was admitted twice, with normal investigations. His symptoms transiently improved during each admission (and with starting levetiracetam) but recurred each time on hospital discharge. Subsequent careful inspection of his medication box identified that his community pharmacy had in error been dispensing baclofen 80 mg per day instead of his prescribed Buscopan 80 mg per day. This case highlights the importance of physically inspecting a patient’s medications and emphasises the spectrum of baclofen-related toxicity; it also highlights potential deficiencies in the pharmacy dispensary process and the need for multiple checks by patients and professionals. ER -