Drug-Induced Telogen Effluvium in a Pediatric Patient Due to Transcription Error

In 2015, a case was reported of a 15-year-old Burmese girl who experienced sudden hair loss, or telogen effluvium, due to a transcription error at the pharmacy. The girl, who was being treated for enthesitis-related arthritis, was mistakenly given methazolamide instead of the prescribed methotrexate due to an auto-complete error in the pharmacy's computer system. The error was discovered when the patient's hair loss was investigated, and it was found that she had been taking the wrong medication. After the error was corrected and the patient was given the correct medication, her hair loss resolved and she showed significant hair regrowth. The case highlighted the potential for new types of errors introduced by computerized medical management systems, and the importance of double-checking prescriptions, especially for patients who do not speak English and may not be able to read their prescription bottles.