I was, as always, in a hurry. I paid the pharmacist's assistant, grabbed the small bag, 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. Still, a tiny doubt bothered me. I read the pharmacy prescription label. Then it hit me. The names were similar, but not the same. I had 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 had assumed it was a fluke.
Now, I had questions.
There is no way to tell how often errors occur. Words like "occasionally", "common", or even "frequent" are used to quantify frequency of errors. The truth is, most errors are reported voluntarily by pharmacists or by the public when they decide to do it, so the numbers aren't accurate.
The US Food and Drug Administration (FDA) reported more than 95,000 errors since the year 2,000. Since the numbers are only voluntarily reported, it is suspected the actual number of errors may be higher.
What this means for you, the customer, is that you need to be aware of the possibility, and learn what you can do to prevent taking the wrong medication.
Getting the wrong dose or wrong medication can lead to serious side effects or death. Be aware of sound-alike or look-alike drug names that are known problems. Here are some examples from the Institute for Safe Medication Practices:
- Pamelor/Panlor DC
There are several complex factors that come into play along the supply chain. Errors occur anywhere between the healthcare provider and the customer.
Some of these involve:
- An error in choosing, writing out, or sending the prescription
- An error in transcribing the prescription instructions
- Improper dose or strength of the medication
- Dispensing the wrong drug or mixing up customers
- Unawareness of drug interactions or allergies
- Lack of monitoring drug dispension
There are several factors that contribute to consumers taking the wrong prescription home. Some factors include:
Stress and distraction for the pharmacy employees
- Heavy pharmacy workload
Economics, which results in too few people working in a busy place
Physician handwriting, which sometimes can be difficult to read
Pharmacy procedures, such as how the drugs are organized on a shelf
being introduced into the market
Hurried customers, who do not take the time to ask questions
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:
- Improve professional standards and training
- Automation and computer cross-checks
- More attention paid to drug naming to avoid sound-alikes
- Changing packaging so that products do not appear the same
- Computer-generated prescriptions instead of handwritten ones
- Redesign of pharmacy drug storage
- Customer education
- Computerized systems that alert pharmacists to potential errors, such as using bar code labels
- Testing of ways to lower pharmacy stress and distraction
Here are some tips on how to protect yourself against medication errors:
Open the bag. Check to be sure that you have been given what you expect.
Do not sign too quickly. The signature is an agreement that you have gotten the information that you need. Check first before you sign.
Read the label carefully. Read every word. Check for the name of the drug and the condition it is being prescribed for. If this information is not on the label, ask the pharmacist to add it. If the medication name is not what you expected, tell the pharmacist. Never assume you are just being given a generic product.
Look at the drug. If it is a refill, does it look the same as the previous batch? If not, ask the pharmacist.
Ask for printed information sheets. In addition, if you are asked by the pharmacist if you need counseling on the medication, say, "Yes!"
Ask questions. Do not be embarrassed to get the information you need. If the question is complicated, ask to speak to the pharmacist.
Never assume anything. Do not take for granted that you have the right medication.
Buy a book. A customer 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.
Take notes. At the doctor's office, write down drug names and what they are for. Compare your notes to your prescription at the pharmacy.
You are a part of your healthcare team. Take time to educate yourself about the medications you and your family take to prevent serious health complications.
10 strategies for minimizing dispensing errors. Pharmacy times website. Available at: http://www.pharmacytimes.com/publications/issue/2010/January2010/P2PDispensingErrors-0110. Published 2010. Accessed November 8, 2013.
About medication errors. National Coordinating Council for Medication Error Reporting and Prevention website. Available at:
Accessed November 8, 2013.
FDA 101: Medication errors. US Food and Drug Administration website. Available at: http://www.fda.gov/forconsumers/consumerupdates/ucm048644.htm. Updated September 3, 2013. Accessed November 8, 2013.
Velo GP, Minuz P. Medication errors: prescribing faults and prescription errors. Br J Clin Pharmacol. 2009;67(6):624-628.
ISMP's list of confused drug names. Institute for Safe Medication Practices website. Available at: http://www.ismp.org/tools/confuseddrugnames.pdf. Published 2011. Accessed November 8, 2013.
Medication error reports. US Food and Drug Administration website. Available at: http://www.fda.gov/Drugs/DrugSafety/MedicationErrors/ucm080629.htm. Updated March 5, 2009. Accessed November 8, 2013.
Prescription information from consumers. State of Connecticut Department of Consumer Protection website. Available at: http://www.ct.gov/dcp/lib/dcp/drug_control/pmp/pdf/prescriptionerrors.pdf. Accessed November 8, 2013.
Strategies to Reduce Medication Errors: Working to Improve Medication Safety. US Food and Drug Administration website. Available at: http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm143553.htm. Updated April 12, 2013. Accessed November 8, 2013.
Last reviewed November 2013 by Michael Woods, 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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