A Case of a Dispensing Error Causing Iatrogenic Orthostatic Hypotension

This is a case report of a patient with Parkinson’s disease and orthostatic hypotension who presented with increasing falls. We discovered that there had been a dispensing error where amiloride (Midamor®) was supplied instead of midodrine. The error was uncovered during a medication reconciliation by our pharmacist; the pharmacist noted that the pills were stamped with the wrong number and the patient’s caregiver noted that at the last refill they had, indeed, changed shape. Beyond providing the impetus for a review of orthostatic hypotension, this case also highlights an easily missed cause of an adverse drug event, and highlights the importance of the multidisciplinary team and engaged patients and caregivers.