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 medicine at the same large, well-known pharmacy. At the time, I had assumed it was a fluke.
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 should not 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 is not an accurate representation of the prevalence of errors because there is no way to capture this number."
Sound-alike or look-alike drug names are known problems. Here are some examples from the Institute for Safe Medication Practices:
Most dispensing errors occur in frequently prescribed drugs. Dr. Tony Grasha, who worked on a project for the National Association of Chain Drug Stores, provides examples of some common errors:
- Premarin (wrong strength)
- Lanoxin (wrong strength)
- Amoxicillin (wrong strength)
- Ortho-Novum (wrong strength)
- Prednisone (wrong drug)
- Procardia XL (wrong strength)
- Synthroid (wrong strength)
- Xanax (wrong strength)
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
(fewer pharmacy employees)
Physician handwriting (a scrawled prescription can be misinterpreted)
(eg, look-alike packages end up near each other on a shelf, or sound-alike medicines are together in alphabetical order)
being introduced into the market
(who do not want to ask the pharmacist a question)
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:
- 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
- Patient education
- Computerized systems that alert pharmacists to potential errors
- 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 medicine, 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 medicine.
Buy a book. A consumer guidebook to prescription medicines, 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.
I know that I will do things differently during my next pharmacy visit! 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."
About medication errors. National Coordinating Council for Medication Error Reporting and Prevention website. Available at:
. Accessed November 17, 2011.
Farley D. Making it easier to read prescriptions.
FDA Consumer. 1995.
ISMP's list of confused drug names. Institute for Safe Medication Practices website. Available at: . Published 2011. Accessed November 17, 2011.
Your medicine: play it safe. Agency for Healthcare Research and Quality website. Available at: . Published February 2003. Accessed November 17, 2011.
Last reviewed November 2011 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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