Inadvertent ophthalmic administration of atropine drops in a hospice patient.

This case report describes a patient who had atropine ophthalmic drops prescribed and dispensed by hospice to be administered sublingually as needed for control of secretions at the end of life. However, even as she stabilized and discharged from hospice, these remained on her medication list. At a subsequent hospitalization, this order was misinterpreted and the drops were ordered to be administered in both the eyes 3 times a day while in the hospital and were included in her discharge medication list. The patient experienced severe blurring of vision until the error was corrected. This case highlights the potential risks of the common practice in hospice of using alternate routes of administration for medications designed for another purpose.