Friday, October 24, 2014
Inquirer Daily News

Knowing reason for each Rx helps prevent errors

It’s not uncommon for us to hear from consumers who’ve been given the wrong medication at their pharmacy. Sometimes patients can be given incorrect information about a drug they’re taking. 

Knowing reason for each Rx helps prevent errors

It’s not uncommon for us to hear from consumers who’ve been given the wrong medication at their pharmacy. Sometimes patients can be given incorrect information about a drug they’re taking. Wrong information about use for blood pressure (now crossed out) was placed on pharmacy label.

Last week we heard from someone whose father was on multiple medications for blood pressure and diabetes. He had an old prescription in his medicine cabinet for glipizide, which is used to help control high blood sugar. At the time the prescription was filled, the patient’s doctor didn’t include the reason for the medication with the original prescription directions. So, to avoid confusion with other medications, the patient had asked his pharmacist to write on the prescription container what the medicine was for.

Rather than retyping the label the pharmacist took a pen and wrote right on the label. By accident though, instead of writing “for blood sugar,” the pharmacist wrote “for blood pressure.”

The patient was already taking different medications to control his diabetes. When he went to the cabinet to get his blood pressure medication he saw the prescription marked “for blood pressure” and took that on top of other drugs for diabetes. As a result, the patient actually took a drug to lower blood sugar, which became too low (a condition called hypoglycemia). He complained of dizziness, light-headedness felt hot and then passed out. The family called 911 and emergency personnel took him to a hospital ER. His daughter told us that he’s fine now, but she wanted us to suggest what others can do to avoid a situation like this.

Here’s what I’d suggest to vastly reduce the possibility of a similar error. 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. And you definitely should. In many cases the information is programmed along with the drug name right in the doctor’s computer system, so it can easily be printed out with the instructions. This is a critically important simple step that helps allay confusion and it also prevents dispensing and administration errors.

As I’ve previously mentioned, knowing the medication’s purpose can help everyone avoid mistakes – even pharmacists and nurses. It adds an important step in the checking process by helping everyone to assure the drug therapy properly matches the intended purpose. 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. Always ask your doctor to include each prescription’s purpose in the instructions.


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Michael R. Cohen, R.Ph. President, Institute for Safe Medication Practices
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Check Up covers major health events in our region and offers everything from personal health advice to an expert look at health reform. Read about some of our bloggers here.

For Inquirer.com. 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
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