Sunday, December 21, 2014

Identifying medications by storage location is risky

You'd be surprised how many medication errors involve patients identify their medication based on the overall appearance of the container and where it is usually stored, never actually reading the label. Doing that is a set up for errors.

Identifying medications by storage location is risky

You’d be surprised how many medication errors involve patients identify their medication based on the overall appearance of the container and where it is usually stored, never actually reading the label. Doing that is a set up for errors.

A man with diabetes mixed up two different insulin products that he takes. He mixed up his long-acting insulin called Lantus and his rapid-acting insulin, Apidra. He stored the insulin vials separately in his refrigerator, normally keeping Lantus in the butter bin and Apidra on one of the main shelves. However, his wife recently cleaned out the refrigerator and accidently switched the two. She put the rapid-acting Apidra in the butter bin and the long-acting Lantus on the main shelf.

The man normally gave himself 40 units of Lantus plus, depending on blood sugar testing, just a few units of Apidra right before meals. But unaware of the switch made by his wife, the next time the man went to use his Lantus he grabbed Apidra instead. He didn’t read the label. Using an insulin syringe, he drew up and gave himself Apidra 40 units, and went on with his day. The next thing he remembered was 2 hours later when he woke up and was lying on the ground, next to his truck, surrounded by paramedics. Because he had taken his rapid-acting insulin, his blood sugar dropped too quickly. Had he taken the correct long-acting insulin, the medicine would have been used by his body gradually throughout the day.

The man is thankful that he wasn’t driving when he passed out. He said that while he has “learned his lesson,” he wanted to share his story so others could learn from his mistake.

Relying totally on where a medicine is stored is risky and can lead to an error. Reading the label each and every time, however simple that sounds, is important. Perhaps storing the medicines in containers with ‘long-acting’ and ‘rapid-acting’ stickers could help differentiate the products. However, diabetics who have vision problems may not be able to read labels or stickers well. In these cases, some people have wrapped adhesive tape or rubber bands around the rapid-acting insulin vial so that they can feel the vial and recognize the correct product.

Also, make sure you read any information your pharmacist gives you about your medicine. Pictured above are some examples of learning guides, including some for insulin products, that can be found on our consumer Web site. These guides review a list of Top 10 Safety Tips for each drug, common side effects, and what to look out for when taking the medicine. The guides also provide good information to know about the medicine.

Also, if you do happen to be a diabetic that takes insulin, an insulin safety center is available on our Web site. It talks about many different types of errors that patients taking insulin have made and provides numerous tips to help reduce your risk of harmful dosing errors.


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Michael R. Cohen, R.Ph. President, Institute for Safe Medication Practices
About this blog

Check Up covers regional health news and a wide array of healthcare topics from pharmaceutical happenings to patient safety. Read about some of our bloggers here.

Portions of this blog may also be found in the Inquirer's Sunday Health Section

Michael R. Cohen, R.Ph. President, Institute for Safe Medication Practices
Daniel R. Hoffman, Ph.D. President, Pharmaceutical Business Research Associates
Hooman Noorchashm, M.D., Ph.D. Cardiothoracic surgeon in the Philadelphia area
Amy J. Reed, M.D., Ph.D. Dual Board Certified Anesthesiologist and Surgical Intensivist
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