Refused Medication Error
A man with end-stage renal disease was admitted with acute renal failure and mental status changes. The patient refused to take his lactulose owing to loose stools. Although nursing staff noted the refusal in the medical record, they did not inform his primary team. When the patient became more confused, a nurse alerted the team but did not describe the missed doses of lactulose. The patient continued to decline and was transferred to the ICU. In the accompanying commentary, Mary Foley, PhD, RN, of the UCSF School of Nursing, explores how medication nonadherence, communication failures, and deficiencies in electronic health records can hinder patient safety and recommends tactics to address these challenges.