Conclusion
Despite the best intentions by both a thoughtful and knowledgeable
caretaker and the patient’s medical team in our case, a medication error
occurred and then persisted, contributing to a longer-than-needed
hospitalization while the patient received IV levothyroxine due to a
concern of poor oral absorption. If the proposed laboratory test and
imaging-based workup had been initiated, her inpatient stay would have
been further extended. It was only when the concept of “trust but
verify” was applied—in this instance, asking the daughter to bring in
the patient’s home medications—that the unintentional home medication
omission was discovered.
The mature clinician will often employ the paradigm of “trust but
verify” in other high-stakes situations, such as personally viewing
critical imaging and speaking directly with the radiologist. Questioning
an admission medication history is an inexpensive and potentially
valuable diagnostic modality. While understanding the efficiency demands
of the busy clinical climate, we propose adopting this principle in
clinical conundrums. Re-verifying a component of the admission
medication history in our case was well worth the time investment; when
in doubt “trust but verify” – it may just reveal the answer.