{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,9,11]],"date-time":"2025-09-11T17:52:44Z","timestamp":1757613164199,"version":"3.44.0"},"reference-count":12,"publisher":"BMJ","issue":"3","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Pract Neurol"],"accepted":{"date-parts":[[2019,12,29]]},"published-print":{"date-parts":[[2020,5]]},"abstract":"<jats:p>A 76-year-old man developed recurrent encephalopathy, visual disturbance, myoclonus, generalised seizures and atonic drop attacks on a background of a gastrectomy for adenocarcinoma and stable chronic lymphocytic leukaemia. He presented to three different hospitals and was admitted twice, with normal investigations. His symptoms transiently improved during each admission (and with starting levetiracetam) but recurred each time on hospital discharge. Subsequent careful inspection of his medication box identified that his community pharmacy had in error been dispensing baclofen 80\u2009mg per day instead of his prescribed Buscopan 80\u2009mg per day. This case highlights the importance of physically inspecting a patient\u2019s medications and emphasises the spectrum of baclofen-related toxicity; it also highlights potential deficiencies in the pharmacy dispensary process and the need for multiple checks by patients and professionals.<\/jats:p>","DOI":"10.1136\/practneurol-2019-002301","type":"journal-article","created":{"date-parts":[[2020,1,30]],"date-time":"2020-01-30T17:15:37Z","timestamp":1580404537000},"page":"243-245","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["Out of sight: a lesson in drug errors"],"prefix":"10.1136","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1345-3079","authenticated-orcid":false,"given":"Soon Tjin","family":"Lim","sequence":"first","affiliation":[{"name":"Clinical Neuroscience, Royal Free London NHS Foundation Trust, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Timothy","family":"Yates","sequence":"additional","affiliation":[{"name":"Clinical Neuroscience, Royal Free London NHS Foundation Trust, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Di","family":"Liang","sequence":"additional","affiliation":[{"name":"Clinical Neuroscience, Royal Free London NHS Foundation Trust, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Heather","family":"Angus-Leppan","sequence":"additional","affiliation":[{"name":"Clinical Neuroscience, Royal Free London NHS Foundation Trust, London, UK"},{"name":"Institute of Neurology, University College London, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2020,1,30]]},"reference":[{"key":"2025090410235958000_20.3.243.1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1742-6723.2006.00805.x"},{"key":"2025090410235958000_20.3.243.2","doi-asserted-by":"crossref","first-page":"584","DOI":"10.1016\/j.medin.2011.02.007","article-title":"[Electroencephalographic burst-suppression pattern due to baclofen intoxication]","volume":"35","author":"Montes","year":"2011","journal-title":"Med Intensiva"},{"key":"2025090410235958000_20.3.243.3","doi-asserted-by":"publisher","DOI":"10.3109\/15563650.2011.654209"},{"key":"2025090410235958000_20.3.243.4","first-page":"169","article-title":"Baclofen intoxication cases in an intensive care unit","volume":"35","author":"Charifou","year":"2016","journal-title":"Anaesth Crit Care Pain Med"},{"key":"2025090410235958000_20.3.243.5","first-page":"348","article-title":"Self-induced drug intoxication in baclofen: of the calm hypotonic coma in the status epilepticus","volume":"74","author":"Thill","year":"2016","journal-title":"Ann Biol Clin"},{"key":"2025090410235958000_20.3.243.6","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1177\/2042098617693571","article-title":"Baclofen overdose mimicking anoxic encephalopathy: a case report and review of the literature","volume":"8","author":"Miller","year":"2017","journal-title":"Ther Adv Drug Saf"},{"key":"2025090410235958000_20.3.243.7","doi-asserted-by":"crossref","unstructured":"Koker A , Arslan G , \u00d6zden \u00d6mer , et al . An intoxication mimicking brain death: baclofen. Acta Neurol Belg 2018. doi:10.1007\/s13760-018-1012-y. [Epub ahead of print: 08 Sep 2018].","DOI":"10.1007\/s13760-018-1012-y"},{"key":"2025090410235958000_20.3.243.8","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM197303082881011"},{"key":"2025090410235958000_20.3.243.9","doi-asserted-by":"publisher","DOI":"10.2165\/00002018-200629110-00001"},{"key":"2025090410235958000_20.3.243.10","doi-asserted-by":"crossref","first-page":"138","DOI":"10.1016\/j.sapharm.2016.12.013","article-title":"Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: a targeted needs assessment using the intervention mapping framework","volume":"14","author":"Kerstenetzky","year":"2018","journal-title":"Res Social Adm Pharm"},{"key":"2025090410235958000_20.3.243.11","doi-asserted-by":"crossref","first-page":"481","DOI":"10.1002\/pds.4188","article-title":"Economic impact of medication error: a systematic review","volume":"26","author":"Walsh","year":"2017","journal-title":"Pharmacoepidemiol Drug Saf"},{"key":"2025090410235958000_20.3.243.12","unstructured":"Rachel A , Elliott EC , Campbell F , et al . Prevalence and economic burden of medication errors in the NHS in England Policy Research Unit in Economic Evaluation of Health & Care Interventions (EEPRU), 2018. Available: http:\/\/www.eepru.org.uk\/prevalence-and-economic-burden-of-medication-errors-in-the-nhs-in-england-2\/ [Accessed Feb 2019]."}],"container-title":["Practical Neurology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/practneurol-2019-002301","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,4]],"date-time":"2025-09-04T17:24:09Z","timestamp":1757006649000},"score":1,"resource":{"primary":{"URL":"https:\/\/pn.bmj.com\/lookup\/doi\/10.1136\/practneurol-2019-002301"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,1,30]]},"references-count":12,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2020,6,2]]},"published-print":{"date-parts":[[2020,5]]}},"alternative-id":["10.1136\/practneurol-2019-002301"],"URL":"https:\/\/doi.org\/10.1136\/practneurol-2019-002301","relation":{},"ISSN":["1474-7758","1474-7766"],"issn-type":[{"type":"print","value":"1474-7758"},{"type":"electronic","value":"1474-7766"}],"subject":[],"published":{"date-parts":[[2020,1,30]]}}}