International Journal of Clinical Pharmacy

, Volume 38, Issue 2, pp 196–198 | Cite as

Lack of pharmacist–physician communication associated with nimesulide-induced oligohydramnios during pregnancy

  • Švitrigailė GrincevičienėEmail author
  • Jelena Volochovič
  • Jonas Grincevičius
Case Report



The consequences of medication errors can be serious, especially in pregnant women. When decision-making is critical, physician–pharmacist communication has the potential to improve patient safety. In this report, we describe the case of a pregnant woman who developed oligohydramnios after taking nimesulide for neuropathic pain. The drug was improperly prescribed by a family physician and mistakenly dispensed by a community pharmacist. Oligohydramnios was observed during ultrasound examination and an iatrogenic cause was suspected. This case is presented to raise awareness that patient safety is threatened because of a lack of physician–pharmacist communication, especially for pregnant patients.


Healthcare professionals are continually at-risk for making errors at work. Effective inter-professional communication should be an organisational tool to prevent adverse events for pregnant women.


Medication error Nimesulide Oligohydramnios Physician–pharmacist communication Pregnancy 



We thank the patient for her consent to publish her case, and the reviewers for their intellectual support.


Nothing to declare.

Conflicts of interest

The authors have no conflicts of interest.


  1. 1.
    Sawdy RJ, Groom KM, Bennett PR. Experience of the use of nimesulide, a cyclo-oxygenase-2 selective prostaglandin synthesis inhibitor, in the prevention of preterm labour in 44 high-risk cases. J Obstet Gynaecol. 2004;24(3):226–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system. Washington: National Academy Press; 2000. ISBN 0-309-51563-7.Google Scholar
  3. 3.
    Schwarz EB, Parisi SM, Handler SM, Koren G, Shevchik G, Fischer GS. Counseling about medication-induced birth defects with clinical decision support in primary care. J Womens Health (Larchmt). 2013;22(10):817–24.CrossRefGoogle Scholar
  4. 4.
    Pecci CC, Hines TC, Culpepper L. How we built our team: collaborating with partners to strengthen skills in pregnancy, delivery, and newborn care. J Am Board Fam Med. 2012;4(25):511–21.CrossRefGoogle Scholar
  5. 5.
    Fernandez-Lamazares CM, Calleja-Hernández MA, Manrique-Rodríguez S, Pérez-Sanz C, Durán-García E, Sanjurjo-Sáez M. Prescribing errors intercepted by clinical pharmacists in paediatrics and obstetrics in a tertiary hospital in Spain. Eur J Clin Pharmacol. 2012;68(9):1339–45.CrossRefGoogle Scholar
  6. 6.
    Ojeleye O, Avery A, Gupta V, Boyd M. The evidence for the effectiveness of safety alerts in electronic patient medication record systems at the point of pharmacy order entry: a systematic review. BMC Med Inform Decis Mak. 2013;13:69–79.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Lainer M, Mann E, Sonnichsen A. Information technology interventions to improve medication safety in primary care: a systematic review. Int J Qual Health Care. 2013;25(5):590–8.CrossRefPubMedGoogle Scholar
  8. 8.
    Law on Pharmacy 22 June 2006 Pub. L. No. X-709.Valstybės žinios 78-3056.Google Scholar
  9. 9.
    Grincevičienė Š, Kubilienė L, Ivanauskas K, Drąsutienė GS, Ramašauskaitė D, Grincevičius J, et al. Experiences of community pharmacists advising pregnant women. Int J Clin Pharm. 2015;37(4):636–44.CrossRefPubMedGoogle Scholar
  10. 10.
    Downe S, Finlayson K, Fleming A. Creating a collaborative Culture in maternity care. J Midwifery Women’s Health. 2010;3(55):250–4.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing 2016

Authors and Affiliations

  • Švitrigailė Grincevičienė
    • 1
    Email author
  • Jelena Volochovič
    • 2
  • Jonas Grincevičius
    • 3
  1. 1.Department of Biothermodynamics and Drug Design, Institute of BiotechnologyVilnius UniversityVilniusLithuania
  2. 2.Centre of Obstetrics and Gynaecology, Hospital “Santariškių Klinikos”Vilnius UniversityVilniusLithuania
  3. 3.Department of Drug Technology and Social Pharmacy, Faculty of PharmacyLithuanian University of Health SciencesKaunasLithuania

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