The Last Line of Defense Against Medication Errors:

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The Last Line of Defense Against Medication Errors:

What You Need to Know to Keep your Family Safe

There is no question that medication errors are a serious problem in the United States. In fact, according to the Institute of Medicine, they are one of the leading causes of death in this country. However, there is something that you can do to help protect yourself and your loved ones from these potentially deadly mistakes.

Copyright © 2004 Timothy McNamara, MD, MPH

This is a true story.

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

(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.” But 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 than 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 errors and improve the safety of pharmacy practice.

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

I can tell you that this sort of medication errors 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 would experience an adverse drug event within three months-and 39% of these are preventable or avoidable.

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

And almost everyone who studies this problem agrees that current systems for selecting drugs, dosing them, communicating a prescription to a pharmacy, dispensing medications, 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.

Twenty years ago, your ability to get current, objective, reliable information on your medications quickly and efficiently 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. A host of online tools, databases, and resources allow you to learn about medications that your physician and pharmacist may not know. And help you prevent medication errors.

We’ll talk about them, show you where 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.

You must become the final line of defense in the battle against medication errors.

We will give you some key rules that should guide your defense against med errors.

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 following:
· 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.

Throughout this series, we’ll talk about specific resources that will help with each of these.

The result, we hope, will be the peace of mind of knowing that you and your family are getting your seven rights:
· right drug;
· right patient;
· right dose;
· right time;
· right route;
· right reason;
· right documentation.

Right on!

© 2004 Timothy McNamara, MD, MPH

Timothy McNamara, MD, MPH, is a nationally prominent medication safety and healthcare technology expert.

Other resources:


Consumer You’re Probably Making


What is the three most common cause of med errors?

The three most common causes of medication errors are incorrect dosage, missed doses, and interactions between drugs.

What can you do to prevent drug errors?

One way to prevent drug errors is to always ensure you are taking the correct medication and taking it in the correct dosage. It is also important to be aware of potential interactions between different drugs. You can ask your doctor or pharmacist about potential interactions and read the drug information sheets that come with your medications.

What do I do if I find a medication error?

If you find a medication error, report it to your pharmacist or prescriber. Do not take the medication unless you have been instructed to do so by your pharmacist or prescriber.

See also:

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Are You at Risk for Kidney Failure?

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