Profound Hypoglycemia in a Mail-Order Pharmacy Customer as a Result of a Dispensing Error

Abstract

Accidental hypoglycemia is most commonly associated with the inadvertent ingestion of oral hypoglycemic drugs, and profound hypoglycemia can result in significant morbidity and mortality. Dispensing errors involving sulfonylureas are usually cited as the cause, and these errors have historically been related to sound-alike compounds or proximity errors. We present the case of a patient who received sulfonylureas meant for a different patient through the mail and simply complied with the instructions on the medication bottle, with the result of severe hypoglycemia. This case demonstrates the need for clinicians to properly assess all patients with profound hypoglycemia, evaluating them for inadvertent ingestion of hypoglycemic agents. Furthermore, pharmacies that provide mail-order prescription services must ensure patient safety through quality-control mechanisms.