By guest blogger Michael Cohen:

As a pharmacist, I sometimes hear health care consumers express concerns about the possibility of getting the wrong medication when they have a prescription filled at the pharmacy. Here’s a tip that will vastly reduce that possibility:

Along with each prescription, make sure your doctor includes the reason for each prescribed medication.

Most doctors don’t include the medication’s purpose automatically, so you’ll often have to request it. You definitely should. This is a critically important yet simple step that helps allay confusion and prevent dispensing errors.

Of the thousands of drug name mix-ups reported to the ISMP Medication Errors Reporting Program over the years, we rarely find look-alike or sound-alike product mix-ups where each drug is used for the same reason. So knowing the medication’s purpose can help everyone – especially pharmacists and nurses – match the prescription’s purpose with the proper drug. It also allows them to verify that the medication is being dosed properly for its intended use (some products have multiple uses, each with a different dosing schedule). And you’ll also have the reason typed right on your prescription container label, so you don’t have to guess later what a medication is for.

Although actual mix-ups are rare, there are scores of drug names that can look similar. Combined with poor doctor handwriting one name can easily look like another, especially if they have similar strengths.  With sound-alike names, prescriptions given by telephone can also be misheard. And doctors are human. So once in a while they slip and order the wrong medication for your condition. The purpose on the prescription can be quite helpful in preventing that sort of error too.

Here's an example of a near miss that was reported to us not long ago when a patient with severe itching brought this prescription to her pharmacist. 

The woman’s physician accidentally prescribed hydralazine, a drug for high blood pressure. He actually meant to prescribe hydroxyzine, an antihistamine. The 25 mg strength is common to each medication. Apparently the doctor made an honest mistake and had the wrong one in mind.

Seeing “hydralazine” and “itch,” the pharmacist immediately recognized that something was wrong since the drug is for high blood pressure, not itch. Without the purpose included on the prescription, chances are hydralazine would have been dispensed. Not only would the patient not get relief for her itch, she may also have suffered very low blood pressure and possibly other serious side effects. The pharmacist contacted the prescriber and had the order changed.

If some sort of stigma is associated with the diagnosis, such as HIV or mental disorder, it’s still possible to include descriptions such as “for infection” or “for mood” to communicate the drug’s intended purpose. Obviously, all health professionals must, by law [The Health Insurance Portability and Accountability Act (HIPAA) of 1996] , keep your health information confidential. That certainly includes pharmacists and nurses.

There’s a grateful patient out there somewhere, simply because her doctor put the reason for the medication right on the prescription. Be sure to ask your doctor to do the same every time a prescription is written for you or a family member. It works fine for typed (computer generated) prescriptions too. It's definitely the safe thing to do.

For information on the Institute for Safe Medication Practices' consumer website go www.consumermedsafety.org
 
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