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.