Earlier this year, a pregnant woman was supposed to get a prescription antibiotic for infection but was accidentally given another woman’s prescription for methotrexate, a medicine that inhibits abnormal cell growth. It’s used for certain cancers and for other conditions like rheumatoid arthritis and psoriasis. But since the drug inhibits cell growth, about the last person that should receive it is someone who’s pregnant, since it can cause birth defects or a miscarriage. How can a wrong patient medication error tragedy like this happen and what can you do to make sure you and your loved ones are protected against such errors?
According to the news reports, the pregnant woman, Mareena Silva, took one dose of methotrexate before she discovered the error. She immediately called her doctor, who told her to go to the hospital emergency department (ED) for evaluation. At the time of the news report, it was too early to determine if the unborn child was injured, and we have not seen any follow-up reports.
The main problem in this case was that both women had similar names. The methotrexate was intended for a woman named Maria Silva. The pharmacist did not ask for her address or date of birth to confirm her identity when she picked up the medicine. Asking for this information to confirm a person’s identity is common in most pharmacies. But if this step is forgotten, mistakes can happen.
In fact, this type of error, where someone is accidentally given someone else’s medication, is among the most common types of pharmacy errors.
You can help avoid receiving another person’s medicines by always providing at least two forms of identification when you pick up a prescription medicine at the pharmacy, For example, in addition to stating your full name, make sure to also give either your address or date of birth. If you are picking up medicine for another person, gather this information before going to the pharmacy. Most pharmacy staff will remember to ask people for this important information to decrease the chance for a mix-up but like other procedures, it may not be followed 100%. To be sure, take the initiative and provide it up front.
If possible, watch to confirm that the pharmacy staff member compares the information you have provided with the prescription receipt. If there are any questions, provide additional information (such as a telephone number or driver’s license) to confirm your identify or the identity of the person for whom you are picking up the medicine.
Always open the bag that holds the medicine. Look at the actual prescription vials and the medicines they contain to verify that the name on the label is correct and that the medicine looks like what you expect. Do these things before you walk away from the pharmacy counter or drive away from a pharmacy drive-through window. If a friend or neighbor is picking up the prescription medicine, open the package to check the contents as soon as you receive the medicine. Call the pharmacist with any concerns or questions you may have.
Most pharmacies ask people if they have any questions or would like to speak to the pharmacist when picking up prescription medicines. Always say, “Yes.” This will give the pharmacist an opportunity to discuss your medicine with you. If medicine for a different person has been given to you, the mistake will likely be noticed right away because the pharmacist will be discussing a different medicine intended for another person. So, talking to the pharmacist can serve as another way to make sure you get the correct prescription. This suggestion does not work if a friend or relative is picking up your medicine. However, you can call the pharmacist if you want to go over your medicines or if you have any questions.
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