The same drug, twice, under two names

Nobody made a mistake in Wilhelmina Ross’s case, which is exactly what makes it worth writing about.

The call happens at day three and lasts as long as it needs to. The median is nineteen minutes; the longest recorded on this service is fifty-two.

Eleven medicines, seven of them intended

Deprescribing is done one agent at a time with a defined review window, and the patient holds a written record of what was stopped, when, and what to watch for.

Two right answers can add up to a wrong list. Nobody owns the list, so nobody checks it.

Samuel Reyes, clinical pharmacy

The annual review

Nothing here is about taking fewer medicines as a goal in itself. It is about the list matching the intention, which is a different and duller objective.

One in six of this service’s discharge calls finds something similar. “It isn’t rare,” says her pharmacist. “It’s just invisible.”