The Last Line of Defense Against Medication Errors: What You Need to Know to Keep your Family Safe

This is a true story.

Yesterday, I picked up a new antibiotic prescription for my daughter from my local pharmacy.

(We recently adopted my daughter from India where she had recurrent ear infections resulting in severe hearing loss. And, she is about to undergo the second of several planned surgeries in order to try to repair the damage.)

Before putting her to sleep, I got the new medication out of the bag, glanced at the instructions, and prepared to give her the drug according to the instructions on the label.

Just before doing so, I had a quick double-take.

Something seemed to be wrong. I looked at the instructions again, and thought to myself slowly, *What*s going on...this doesn*t seem right.* Then, it hit me that the dose seemed awfully high for her.

It took me a minute or two to put the pieces together (it had been an unusually tough fight getting her ready for bed, I was tired, I was confident in my daughter*s physician, and I was thinking perhaps less critically that I should have). And then I noticed it. The label had a stranger*s name on it.

After another moment or two, I saw what had really happened.

The medication came in a box. Each side of the box had a different label...one label was for my daughter and one label was for a stranger. And, the stranger*s dose was more than double what my daughter*s surgeon had recommended.

(This error didn*t happen in a mom-and-pop pharmacy. It happened in a modern new chain pharmacy whose name you would recognize from advertisements on TV.)

I*m not a surgeon...and I*m not a pediatrician...but I am a physician trained in internal medicine and I have spent most of the last twelve years writing about, speaking about, and developing systems to reduce the frequency of medication error and improve the safety of pharmacy practice.

This pharmacy error brought the topic of drug safety home to me...literally.

What I can tell you is that this sort of error occurs all too often in the United States (and around the world). And, that it can have devastating consequences for the people involved.

A recent study in the New England Journal of Medicine indicated that 25% of patients who take one or more prescription medications will experience an adverse drug event within three months-and 39% of these are preventable or avoidable.

The Harvard Medical Practice Study found reported in JAMA in 2001 that 30% of patients with drug-related injuries died or were disabled for more than 6 months.

And, what almost everyone who studies this problem agrees is that current systems for selecting drugs, dosing them, communicating a prescription to a pharmacy, dispensing drugs, and instructing patients on their safe use are woefully inadequate.

In this series, we are going to take a close look at the processes that cause medication errors (some things that your physician and pharmacist may not even want you to know) and what steps you can specifically take to make sure that you and your love ones are protected from this hazard.

Ten years ago, your ability to get current, objective, reliable information on your medications in a quick and easy way was practically non-existent. It probably would have involved a trip to the library and required considerable knowledge about pharmacology to get the answers.

Today, that*s not the case. There is a host of on-line tools, databases, and resources that allow you to learn information about medications that even your physician and pharmacist may not know.

We*re going to talk about them, show you were to go, tell you the key things you need to know about medications, expose some myths, and let you know the questions you should be asking. It*s not as hard as it may seem.

In fact, you need to become the final line of defense in the battle against medication errors.

Throughout, we are going to give you some key rules that should guide your defense.

So, Rule Number 1. Trust, but verify. Never assume that the medication you have received is the right medication for you or that it is dosed correctly for you. Specifically, you should check:

• the name of the patient on the bottle;

• the name of the doctor on the bottle;

• the name of the medication (and cross check it to be sure that it treats a disease or problem you actually have... there are lots of look-alike/sound-alike drug names out there);

• the dose (from an independent source...to make sure that it is a plausible dose for you);

• the *route* (to make sure, for example, that eye drops are being prescribed for the eye, and not the mouth, or the ear...amazingly injuries from drug misplacement occur all the time);

• the expiration date.

We*ll talk about some specific resources that will help with each of these throughout this series.

The result, we hope, will be the piece of mind to know that you and your family are getting your 7 rights:

• right drug;

• right patient;

• right dose;

• right time;

• right route;

• right reason;

• right documentation.

Right on!

© 2004 Timothy McNamara, MD, MPH

About The Author

Timothy McNamara, MD, MPH is a nationally prominent expert in medication safety and healthcare technology. For additional practical steps you can take to improve medication safety and a personalized report of your medication profile, go to: http://www.medicationadvisor.com/art1.asp

---

An Introduction to Acid Reflux Disease

Acid reflux disease, also known as Gastroesophageal Reflux Disease or... Read More

Phentermine Price Watch: Comparison Shop To Buy Phentermine At The Best Values Online

When compared with the other prescription diet pills, Phentermine is... Read More

Rogue Online Pharmacies: The Internet War Of 2005

Online Pharmacy owners who haven't been working within moral and... Read More

Understanding Tumescent Liposuction

Tumescent liposuction is done using a local aesthetic. A large... Read More

Carpal Tunnel Syndrome - Steroid Injection for Carpal Tunnel Syndrome

What is the role of steroid injection in carpal tunnel... Read More

You Are Getting Very Sleepy....The Truth about Hypnosis

A hypnotic "trance" is not something that is foreign to... Read More

Warning! Flu Shots Can Be Dangerous To Your Health

Every year about this time doctors around the world are... Read More

Why Our Healthcare System Isnt Healthy

Most people are well aware that an estimated 45 million... Read More

10 Home Remedies For Arthritis Pain Relief

Your Remedy No. 1 ==============Stretch Gently for Strength and Mobility.When... Read More

FDA Orders Search Engines to Stop Online Pharmacies

How Does Online Pharmacies Affect Pharmacy Leaders?With cheaper drugs made... Read More

Lipitor Side Effects

Lipitor is a drug intended to help lower cholesterol. The... Read More

How Safe Do You Feel Going To Hospital To Be Cured

There has been a lot of concern in Australia over... Read More

Prescription Drug Benefit Cost Understated by $324 Billion!

When the legislation was passed for Bush's prescription drug benefit... Read More

A Guide to Arthritis Pain Relief

In a recent survey on pain conducted by the Stanford... Read More

Death by Fluoride

A wee bit of fluoride makes teeth and dentists happy,... Read More

The Right Stethoscope For Your Needs!

Just about all health care providers have need of stethoscopes.... Read More

rX My Heart and Hope to Die

This must be a mistake! How could his drug costs... Read More

Anxiety Management With Prescription BuSpar: Don?t Worry, Be Happy

We've all had one of those weeks: the washing machine... Read More

Are You Suffering From Addiction?

Many researchers believe that addiction is a behavior that can... Read More

Online Pharmacies and the FDA

The FDA (Food and Drug Administration) is responsible for overseeing... Read More

The Pharmaceutical Drug Cartel and the FDA

According to the Los Angeles Times, the California Association of... Read More

Phenylpropanolamine (PPH) Lawyer: Decongestant Causes Stroke

Phenylpropanolamine, or PPH, used to be an active ingredient in... Read More

CT and MRI Scans in Neurological Practice: A Quick Overview

Before computed tomographic (CT) scans became available in the 1970s,... Read More

3 Facts Everyone Should Know About Stem Cells

Cord BloodCord Blood is the blood that remains in the... Read More

Heart Disease: The Dangers Of Coronary Heart Attack And How To Avoid It

What is a coronary heart attack?Are you at the risk... Read More