The first time I (Dr. Larson) reviewed Ms. D's chart, I was stunned by her nearly weekly visits to the emergency department. Her problem list stretched on and on, including diagnoses of falls, hypokalemia, edema, confusion, chronic back pain, history of polysubstance abuse, anxiety, and hypertension. A review of her medications revealed the cause of many of her issues: an overwhelming combination of muscle relaxants, gabapentin, multiple antihypertensives, antiemetics, and two serotonin-norepinephrine reuptake inhibitors (SNRIs). During our weekly visits, we slowly unraveled the tangle of medications and their interacting effects. One antihypertensive was contributing to edema, which had led to the addition of a diuretic that contributed to hypokalemia — a prescribing cascade¹ that caused the patient direct harm.

Duplicative SNRI therapies for different indications (back pain and anxiety — one prescribed by a psychiatrist and another by primary care) had caused serotonin syndrome, leading to elevated blood pressure, falls, and worsened anxiety. To mitigate the anxiety, Ms. D had taken benzodiazepines and opioids left over from previous prescriptions, leading to another fall. Labeled in her chart as “non-compliant,” she had actually attempted to adhere to a drug regimen that was causing harm. Flawed medication reconciliation and refill workflows, along with a lack of communication across specialties, further complicated the care of her already complex physical and mental health needs.