I was, as always, in a hurry. I grabbed the small bag, scribbled a check for the pharmacist's assistant, and dashed out. The next morning, I opened the new container. My pills were blue. Huh? I thought the company must have changed the color. But a tiny doubt bothered me. I read the pharmacy prescription label.
Then it hit me. The names were similar, but not the same. I'd almost taken the wrong drug.
The same thing had happened to me a few months earlier with another medication at the same large, well-known pharmacy. At the time, I'd assumed it was the rarest of flukes.
Now, I had questions.
Experts use words like "common" and "frequent," but statistics vary. Most errors are reported voluntarily by pharmacists or patients. Lisa Stump, MS, RPh, clinical coordinator of drug use policy at Yale-New Haven Hospital, says this is an unreliable way to determine frequency.
But Stump believes we shouldn't be focusing on statistics. "We know medication error is common. Quantifying the incidence will not assist us in making changes we already know need to be made," she says.
Marci Kropff, PharmD Fellow of the Institute for Safe Medication Practices, agrees. "We don't encourage a focus on statistics. The information isn't an accurate representation of the prevalence of errors because there's no way to capture this number."
Sound-alike or look-alike drug names are known problems. Here are some examples:
Most dispensing errors occur in frequently prescribed drugs. Tony Grasha, PhD, is a University of Cincinnati psychology professor working on a National Association of Chain Drug Stores project to reduce prescription errors. He names the following drugs as being among the top 10% of the most troublesome medications with regard to errors in the last five years:
There are several factors that contribute to consumers taking the wrong prescription home. Some factors include the following:
Customers, pharmacists, doctors, and professional organizations are all serious about minimizing errors. Many pharmacists routinely stay after work to recheck prescriptions they filled that day.
Some of the many methods of reducing errors include the following:
Here are some tips on how to protect yourself against medication errors:
Open the bag . Check to be sure that you've been given what you should have. Grasha, in his onsite pharmacy study, watched hundreds of customers.
"Three-quarters immediately open and examine their photos at the film center. Less than one-third of pharmacy customers look inside the bag," he notes.
Don't sign too quickly . The paper pushed across the counter—the one most of us sign automatically—is an agreement that you've gotten the information you need. Don't sign it without checking first.
Read the label carefully . Read every word. Check for the name of the drug and the condition it's being prescribed for. If they're not on the label, ask the pharmacist to add them. If the name isn't the name your doctor told you he was prescribing, ask the pharmacist. Never assume you're just being given a generic product.
Look at the drug . If it's a refill, does it look the same as the previous batch? If not, ask the pharmacist.
Ask for printed information sheets . And if you're asked by the pharmacist if you need counseling on the medication, say "Yes!"
Ask questions . Don't be embarrassed to get the information you need. If the question is complicated, ask to speak to the pharmacist.
Never assume anything . Don't ever take for granted that you have the right medication.
"Two-thirds of errors are caught by customers," Grasha says. "Errors are part of the system and consumers are a very important part of the process."
Buy a book . A current consumer guidebook to prescription medications, with colored illustrations, should be part of your home library.
Keep a record . Write down information about each of your prescriptions. Grasha suggests taping one pill on an index card and writing down the name, what the medication is for, the dose, and color/markings. Or put the same information, along with a sample, into a separate envelope for each medication.
Take notes . At the doctor's office, write down drug names and what they're for. Compare your notes to your prescription at the pharmacy.
Next time, I'll know to do things differently. As Stump says, "Consumers must make the effort to educate themselves, to partner with their doctors and pharmacists to protect their health. Healthy patients are everyone's goal."
RESOURCES:
National Coordinating Council for Medication Error Reporting and Prevention
http://www.nccmerp.org/
The Institute for Safe Medication Practices
http://www.ismp.org/Consumer/Brochure.html
CANADIAN RESOURCES:
Canadian Pharmacists Association
http://www.pharmacists.ca
College of Pharmacists of British Columbia
http://www.bcpharmacists.org/you_your_pharmacist/index.php
References
About medication errors. National Coordinating Council for Medication Error Reporting and Prevention website. Available at: http://www.nccmerp.org/ .
Farley D. Making it easier to read prescriptions. FDA Consumer . 1995 Jul-Aug.
How to take your medications safely. The Institute for Safe Medication Practices website. Available at: http://www.ismp.org/Consumer/Brochure.html .
Last reviewed November 2009 by Brian Randall, MD
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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