Background: A significant percentage of elderly patients suffer from both polypharmacy and visual impairment. This combination can increase the risk of an adverse event related to medication. This case highlights an unusual, but potentially deadly, medication adverse event.
Case presentation: A 77-year-old male, visually impaired, ingested a pill desiccant, believing it was the ampicillin/sulbactam tablet he was prescribed for an infected diabetic foot ulcer. He presented to the emergency room with inability to swallow, and imaging revealed the pill desiccant lodged in his upper esophagus. He developed respiratory distress due to aspiration of secretions, necessitating intubation both to protect his airway and for an esophagogastroduodenoscopy (EGD). During EGD the desiccant was pushed into the stomach due to an inability to remove it without causing harm. Patient self-extubated the following day and per family and patient's wishes was not re-intubated. The patient suffered no further complications directly related to the desiccant, but he died several days later from respiratory failure.
Conclusions: This case highlights a concerning medication patient safety issue for visually impaired geriatric patients.
Keywords: Adverse medication event; Functional status; Geriatric patients; Patient safety.