Recurrence of adverse drug reactions following inappropriate re-prescription: better documentation, availability of information and monitoring are needed

Drug Saf. 2010 Jul 1;33(7):535-8. doi: 10.2165/11532350-000000000-00000.


Adverse drug reactions (ADRs) are a common, and often preventable, cause of hospital admission, especially in the elderly, and can occur during hospitalization. In this current opinion article, we present three cases of recurrence of a serious ADR due to re-prescription of a withdrawn medication that highlight the need for a system to prevent the undesirable re-prescription of medications withdrawn because of an ADR. In addition, we describe an electronic system that could help prevent undesirable re-prescription following an ADR. Such a system should document ADRs systematically at the patient level, make this information available to relevant healthcare providers and the patient, and flag re-prescription of the offending drug. The effectiveness and cost effectiveness of such a system would need to be determined.

Publication types

  • Case Reports
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adverse Drug Reaction Reporting Systems* / standards
  • Aged, 80 and over
  • Diclofenac / administration & dosage
  • Diclofenac / adverse effects
  • Diclofenac / therapeutic use
  • Drug Prescriptions* / standards
  • Drug Prescriptions* / statistics & numerical data
  • Drug-Related Side Effects and Adverse Reactions / chemically induced
  • Drug-Related Side Effects and Adverse Reactions / diagnosis
  • Drug-Related Side Effects and Adverse Reactions / prevention & control*
  • Female
  • Humans
  • Hydrochlorothiazide / administration & dosage
  • Hydrochlorothiazide / adverse effects
  • Hydrochlorothiazide / therapeutic use
  • Medication Errors*
  • Middle Aged
  • Secondary Prevention


  • Hydrochlorothiazide
  • Diclofenac