Preventing Medication Mishaps

Joan Jackson
By Joan Jackson September 15, 2015 11:03


Links to easy online templates for medication lists are listed at the end of this article.

When you pick up your prescription at the pharmacy, do you open the bottle and examine the new pills, or do you simply pay the bill and leave?

Medications can enhance or even save your life when used correctly, but they can be dangerous and even deadly when they are not. Medication mishaps result in some 18 million emergency rooms visits across the nation each year and nine million hospitalizations, according to the Institute for Safe Medication Practices, a Pennsylvania-based watchdog group.

John Frank, a pharmacist at Sonora Regional Medical Center, urges medication users to become smart consumers.

“Always check the medication to see if it looks right,” he says. “Talk to your pharmacist if it doesn’t. It may be the wrong medication, or it may just be from a different manufacturer.”

One-third of all adults in the U.S. take five or more medications each day, according to the Institute of Medicine, part of the National Academies of Sciences, Engineering and Medicine.

Nationwide, more than four billion prescriptions are filled each year – 445 million of them in California – and the number is climbing. Total retail sales for prescription drugs filled at U.S. pharmacies in 2014 topped $259 billion, according to the Kaiser Family Foundation. That’s up from $40.3 billion in 1990.

The foundation also reports that more than $42 billion in over-the-counter medication is sold annually.

In general, as you get older, the more doctors you see and the more medication you take – and your risk for drug mistakes rises correspondingly. By the time you are 65, you are seven times more likely to fall victim to a drug error, whether that mistake is your own or a health care provider’s.

In a 2004 study, Express Scripts, which manages prescription benefits for tens of millions of U.S. residents, revealed that a senior receiving treatment from two physicians has an average of 27 prescription fills per year and is at risk of 10 drug errors. A senior with seven doctors receives an average of 52 prescription fills per year and the drug error risk more than doubles to 22 per year.

Since that study was released, prescription drug use in the U.S. has risen each year.

The potential for prescribing and dispensing errors is alarming. Mistakes can be made in the doctor’s office, the hospital, the pharmacy or a skilled nursing facility, and can take many forms:

  • A specialist may not know the other medications a patient is taking and prescribes a drug that interacts negatively.
  • A misplaced decimal point leads to an incorrect dosage.
  • A scribbled prescription is misinterpreted and the wrong medication dispensed.
  • Drug names are confused and the wrong one goes to the patient.
  • Prescriptions for two patients are inadvertently swapped.

Patients also make mistakes. As people age, eyesight and hearing often decline. It’s harder to read the prescription instructions or hear what the doctor or pharmacist has to say. Diseases such as Alzheimer’s make following instructions even more difficult.

On average, half of all patients take their medications incorrectly, according to the New England Health Care Institute, a health policy research organization. That number increases with age and the number of medications taken.

Those mistakes can prove fatal. The Centers for Disease Control attributes 125,000 deaths each year to patient medication errors.

So how can you keep yourself safe?

Registered nurse Linda Winn, Calaveras County’s public health manager, joins Frank in urging patients to become active, savvy consumers.

“Ask your physician questions,” says Winn. “Ask why you’re taking a medication, ask about side effects and ask what to watch for.”

You should also share information with your health care providers. Let your doctor know if you can’t afford a medication or can’t take it as prescribed. Sometimes low-income patients split pills or let prescriptions wait until the next paycheck comes.

When you don’t take your medications as prescribed, the healing process can slow down or symptoms can become worse, and your doctor won’t understand why.

“Your doctor needs to know, or he’s going to think he needs to increase the dosage,” Frank says. That dosage increase will likely cost more and may cause harmful side effects. “Communication is very important.”

Top Tips to Prevent Medication Mistakes

Ask your doctor what a medication is for, how to take it and what to expect from it. Ask how you will know the medicine is working. Some medications take time to build in your system. Know how much you should take, when, for how long and if it should be taken with food. Ask about potential side effects and what to do if you experience an adverse reaction. Ask how a new medication will interact with the others you are taking. Take detailed notes and read them back to your doctor to make sure you understand.

If you suddenly have trouble breathing, call 911 immediately. If you develop a serious reaction, such as a skin rash, hives, swelling or wheezing, stop taking the medication and call your doctor.

Make sure each of your health-care providers knows every medication you are taking. The more doctors you have and the more medications you are taking, the higher your risk for errors and negative drug interactions. Make sure your doctors are well-informed about your regimen.

Make a list of all your medications and print two copies. Keep one copy in your purse or wallet and put the other in a sealed envelope on your fridge, available to first responders in case of emergency. Several good list templates are available online (see below).

Add allergies to your list. Describe any reaction you have experienced, such as allergies or bad side effects, that required you to stop taking a particular medicine. Include any allergy to dyes, foods or insects, and note what happens to you if you are exposed to these things. Talk to your doctor before striking a medication off the list, advises Frank. A dry mouth may be an uncomfortable but acceptable tradeoff for getting the most effective medication.

Keep each medication in its original container with labeling intact. If there’s a problem with the medication or a recall, it’s important to have the original label with the lot number and date. Only put what you need daily or weekly into your plastic medication dispenser. When you dispose of the empty container, scrape the label off to protect privacy.

Store medications securely. “Make sure they’re out of reach of your grandchildren,” warns Frank. Also make sure your pets can’t get at them, as many medications that help people can cause sickness or even death in dogs and cats. Discard expired medications. Check the Federal Drug Administration website ( for information on responsible disposal. Foothill law enforcement and health agencies can provide information about periodic used-prescription drop-off programs.

Check with your physician before taking over-the-counter vitamins or supplements. Frank says these are often a waste of money and can actually interfere with prescribed medications. “Spend your money on a good diet instead,” he advises.

Don’t share your medications with family or friends. It is potentially dangerous to use someone else’s prescription drugs, and if your doctor doesn’t know what you are taking, it is impossible to prescribe for you safely and accurately.

If your medications come by mail, remove them from your mailbox right away. “In the summer they’re getting cooked,” Frank says. They may not function effectively after exposure to excess heat or cold.

Always use the same pharmacy if possible. Your pharmacist is a great ally in keeping you safe, advises Winn. When starting a new medication, ask your pharmacist for a consult so you’re clear how to take it. Also make sure he or she has an up-to-date copy of your medication list. Pharmacists are a final line of defense if a potential drug interaction slips past your doctors; many now use databases that can flag drug interaction threats. If you are considering ordering medications online and are not familiar with the company, be aware that distribution of counterfeit drugs is rampant.

Don’t take anything for granted. Ask your doctor and pharmacist lots of questions and keep asking – especially when you have a gut feeling that something isn’t right.

Take your medicines. With all the concerns around safety, remember that your medications are prescribed to help support and improve your health. Be an informed consumer, then take your medicine.

Online Templates Make Medication Lists Easy

Your list should include your name, address and phone numbers, an emergency contact’s name and phone number and the names and numbers of all your health care providers. In an emergency you may not be able to share that information.

Write the brand and generic name of each medicine, your dose and how often and how you take it. If you stop taking a certain medicine, draw a line through it and list the date you stopped taking it.

Include all prescription, over-the-counter, herbal, vitamin and diet supplements. Also list any medicine you take only occasionally, like pain relievers, sleeping pills or medications for heart or respiratory discomfort.

You can create your own medication list by hand or do it the easy way. Numerous websites offer downloadable forms that you can complete and save to a flash drive or print out to fill in by hand. Three are listed here – pick the one you like best. Remember to save copies of the old lists as you update. That way you’ll have a record of all past medications and how they worked for you. Note: Be sure to type the full address into your browser exactly as written below.

Food and Drug Administration

Institute for Safe Medication Practices

UC Davis Health System

Copyright © 2015 Friends and Neighbors Magazine

Joan Jackson
By Joan Jackson September 15, 2015 11:03
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