Objective: This is a case report of a patient with sleepwalking likely caused by tapentadol ER secondary to higher than the recommended dose for the treatment of pain. Methods: This report presents the relevant patient history, laboratory data and literature review on possible causes of this patient’s sleepwalking. Results: A 39-year-old female reported sleepwalking as the dose of tapentadol increased above the recommended maximum provided in the package insert. The mechanism of action of tapentadol involving norepinephrine reuptake inhibition affecting the central nervous system, higher dosage and drug interactions with other home medications likely contributed to her sleepwalking. Conclusion: This case highlights the importance of adhering to the recommended dosage of a medication and if it is clinically warranted to exceed the maximum recommended dose, the importance of diligent monitoring for any adverse effects.

The aim of this article is to describe the pharmacist-managed dofetilide initiation program at Maine Medical Center (MMC), assess the adherence rate to 8 core clinical metrics, and review adverse effects before and after a root cause analysis (RCA). Core clinical metrics included pharmacist note entered within 4 hours of dose administration, dose chosen correctly per renal function, QTc measurements obtained and reviewed 2 hours after each dose, appropriate dose adjustment per the most recent QTc measurement, documentation of patient education, and assessment of conduction abnormality, drug–drug interactions, and serum potassium and magnesium concentrations. The primary outcome was adherence rate to all 8 core clinical metrics before and after the RCA. The safety outcome was the total number of adverse events. One hundred patients undergoing elective dofetilide initiation were evaluated: 50 pre-RCA and 50 post-RCA. Adherence rate to all core metrics was 14% in the pre-RCA group and 44% in the post-RCA group ( P < .001). Torsade de pointes occurred 3 times in the pre-RCA group and never in the post-RCA group. After the RCA, adherence to MMC’s pharmacist-managed inpatient dofetilide initiation program significantly improved.