Special Report – Protect Yourself From Medication Errors

Prescription errors continue to be on peoples minds and often make

national headlines. Medication errors can happen in hospitals,
pharmacies, doctors offices, nursing homes, and your home. In fact,
medication errors can occur anywhere drugs are prescribed or
dispensed and can occur at any time.

Medication Error Definition

Here is the definition of a medication error provided by The National
Coordinating Council for Medication Error Reporting and Prevention
(NCC MERP).

A medication error is "any preventable event that may cause or

lead to inappropriate medication use or patient harm while the
medication is in the control of the health care professional,
patient, or consumer. Such events may be related to professional
practice, health care products, procedures, and systems,
including prescribing; order communication; product labeling,
packaging, and nomenclature; compounding; dispensing;
distribution; administration; education; monitoring; and use."

As you can see, a medication error can occur at any time and can
involve anyone in the process of getting the correct medication to the
intended person. Everyone involved in the process also has a
responsibility to try to prevent an error from happening. Yearly,
community pharmacies dispense over 3 billion prescriptions. It is
estimated the error rate in the dispensing process is between 0.26%

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and 24%. Many of these errors are significant enough to cause harm.

The Institute of Medicine published a report in 2006 estimating there to

be at least 1.5 million adverse drug events in the United States every
year. This number includes all settings such as hospitals and long term
care facilities. They state the true number may be even higher.

To combat medication errors all the medical professions are working

on ways to reduce errors in their respective environments. In order for
these efforts to be effective the Institute of Medicine states a
comprehensive approach is required to prevent errors from happening.
There will need to be changes from doctors, nurses, pharmacists,
other health professionals, the Food and Drug Administration, other
government agencies and from patients.

You, the patient or caregiver, need to be directly involved in preventing

errors and there are lots of things you can do to take an active role.

Here are the 6 major tips promoted by the FDA

● Know the names of your medications - Ask the doctor the drug
name when he writes a prescription so you can tell if you are
given something different when you get the prescription filled.
Many people just accept the prescription from the doctor without
knowing which medication was prescribed. If you don't know
which medication the doctor prescribes, you won't be able tell if
the pharmacy fills it incorrectly.
● Ask questions - How do I take this? What can I expect? What if I

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miss a dose? What side effects are possible? All these

questions help you to understand your medications. By knowing
about the medication you are more likely to notice if a mistake is
made.
● Know what the medication is for - By knowing what your
medication is used for you are more likely to understand how to
take it, what to expect from the medication, and you will be better
able to report if you are having problems with it.
● Read the medication's labels and follow the directions - Before
you use a medication you should know when to use it, how much
to take, how frequently and for how long. Read the label every
time. There are many reports of people taking the wrong
medicine in the middle of the night because they did not turn on
the light to read the label. Also, reading the label ensures you are
getting the correct dose. Don't trust your memory for the correct
dose, many people have taken the wrong quantity by trusting
their memory.
● Tell all your healthcare providers all of your medications - You
should keep an up to date list of the medications you take. This
should include prescriptions, over the counter medications,
vitamins and herbal/natural products. They cannot make an
informed review without complete information. The easiest way
to do this is to download this universal medication form and use
it according to the instructions.
● Keep this list with you - You should have this list with you at all

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times and let a loved one know where you keep it. You should
also have a copy at home.

Follow these tips from the FDA and you are less likely to encounter
medication errors. But there are other steps you can take to prevent
errors that go beyond the FDA's suggestions. Here are some
additional tips from PharmerDon. These come from many years of
experience working as a pharmacist as well as education and research
related specifically to medication errors.

Additional Tips from PharmerDon

● When the doctor writes a prescription, make sure you can read
it. The prescription should be clearly written with no
abbreviations which are often misinterpreted. A type written or
computer generated prescription is even better. Many people
joke about doctor's poor handwriting but this is not a laughing
matter. Many mistakes have happened due to illegible
handwriting. Do not tolerate poor handwriting on your
prescription. Your life may depend on it.

● Avoid letting the doctor's office call the prescription in to the

pharmacy. There is less chance of an error if you bring the
prescription to the pharmacy or the doctor sends it electronically.
The person calling in the prescription sometimes is not familiar
with the correct pronunciation and may say it in a way that
sounds like a different medication. Another way a mistake can be

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made is when the person phoning in the prescription is in a hurry

and rushes through the phone call.

● Stay with one pharmacy for all of your prescriptions. If all your
medicines are on file in one location the pharmacist can screen
for interactions and other problems. With fierce competition
between pharmacies it is tempting to get some $4.00
medications in one location, free antibiotics in another and move
from pharmacy to pharmacy in search of the latest gift card
promotion. This practice could set you up for potential problems
such as drug interactions and overlapping therapy when your
pharmacies are not aware of your complete medication list.

● Avoid transferring your prescriptions from one pharmacy to

another. I have seen errors occur when a prescription is
transferred between pharmacies. Some people pharmacy hop
because of the “free gift card” when you transfer a prescription.
The more a prescription is moved around the greater the chance
for a mistake. If you must transfer a prescription due to traveling,
bring in the prescription bottle from the sending pharmacy and
give it to the receiving (filling) pharmacy. This decreases the
chance of a mistake during the transfer.

● Periodically (about every 6 to 12 months) ask your doctor to

review your medications. Ask if there are any that can be
stopped or if there are potential problems. You can ask your
pharmacy to do the same.

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● Take an active role in understanding your medicine and

managing your condition. The more you know about your
medicine and your condition the more likely you will receive
appropriate therapy and the lower the chance of an error getting
past you.

● Be aware some medications are available in more than one

dosage form (such as tablet, capsule, plain, extended release)
and verify you are receiving the correct one. This is a very
common source of mistakes. I have seen tablets given when a
suppository is ordered or an immediate release medication
prescribed when an extended release medication was needed.

● Always verify the medication you received from the pharmacy is

the same the doctor wrote on the prescription. For refills verify
the medication looks the same as the previous time. Question
any differences you notice.

● Always keep medications in the original container with the

pharmacy label on it. The label identifies the medication and
provides dosing information. Combining all your medications into
one bottle for convenience increases the chances of taking the
wrong medication.

● Don't take someone else's medications. It may not be right for

you or it may interact with your other medications.

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Conclusion
Remember, everyone is human and capable of errors. No one wants to
make a mistake but it only takes a brief lapse of concentration for
someone to make a potentially serious mistake. Do your part, be
involved and ask questions. You are the last one involved in the
medication administration process. Be confident the medication you
are taking is the correct one for you.

Follow these basic principles of medication therapy. Double check

every time to make sure you have:

● The right medication

● For the right person

● In the right amount

● At the right time

● By the correct route (swallow, chew, apply etc.)

With the large number of medications the average person uses each
year, the chance of being involved in a medication error in your lifetime
is quite high. Follow these guidelines and stay alert to ensure
medication safety for you and you family.

You can get more information about medication safety at

www.learnaboutrxsafety.org and at ISMP

Keep a record of all your medications by using a Universal Medication

Form this link is to the best one I have ever seen.

Report an error http://www.fda.gov/medwatch/how.htm