Two years ago, an investigation looked at 45 fatal errors with medicines that were taken by people in their home.4 The medicines most frequently involved in the fatal errors at home included:
• Opioid pain relievers (20 cases)
• Antipsychotic medicines (17 cases)
• Insulin (5 cases)
• OTC medicines (5 cases)
• Heart medicines (4 cases)
• Medicines that prevent blood clots (anticoagulants) (3 cases)
• Medicines used to treat seizures (2 cases)
This study exposed some commonly held myths about medicines that played a role in these deadly errors.
I. Myths related to how medicines work
In this study, the most common errors were caused in part by not understanding how medicines work and the risks associated with taking medicines. Examples of two common myths that played a role in these errors follow.
“If one is good, two will be better.” Many of the errors involved taking or giving more medicine than prescribed or recommended on the medicine package. If the person’s condition or pain had worsened, they disregarded the doctor’s instructions or the directions on the medicine labels and took extra doses without seeking medical advice. Or they took “as needed” medicines routinely instead of only when needed. It appears that most people who took extra doses were unaware that a higher dose would increase the risk of potentially deadly side effects, even with OTC medicines. The following is an example of a fatal error associated with this myth.
An elderly woman with pain in her legs from arthritis and a blood circulation disorder died of complications from using too much of an OTC Chinese herbal cream containing methyl salicylate. This is the same ingredient found in many muscle creams, like BenGay and Icy Hot. Methyl salicylate is related to aspirin, and taking large amounts can be poisonous. The Chinese herbal medicine was intended to be applied once or twice each day on the legs to ease pain. The woman was frequently seen applying the medicine at least 4 times each day. She would hide the medicine from the rest of the family after being reminded to use it less often. Overuse of the herbal medicine led to multiple medical problems, which contributed to her eventual death.
“What works for me will work for you.” Prescription medicines should not be shared from one person to another. In a few instances, well-meaning people shared their prescription medicines with others. They did not understand how the medicine works or that a medicine’s effect depends upon the individual’s medical conditions and their tolerance to the medicine. Some people also felt their symptoms were not being adequately handled by their doctors. This may have led them to use medicines shared with them by a friend or family member. An example follows.
A man with chronic pain from a work injury was found dead at home. A very high dose fentanyl patch (100 mcg/hour) was found on his body, although the medicine had never been prescribed for him. The man told his wife that the patch had been provided by a friend. Fentanyl patches contain a very powerful opioid pain medicine intended only for patients who are tolerant to very high doses of opioids. (Tolerance occurs when a person requires greater amounts of the medicine over time to obtain the desired effect. The patches are available in various doses, from 12 mcg/hour up to the highest available patch dose, 100 mcg/hour.) The man had been wearing a 100 mcg/hour patch, and he was not used to taking high doses of pain medicines. His death was attributed to too much fentanyl in his system, which caused him to stop breathing.
II. Myth related to safe storage of medicines
Some of the fatal errors in the home involved children who gained access to either OTC or prescription medicines. An example of a common myth associated with childhood poisonings follows.
“Accidental poisonings in children won’t happen if I store all my medicines up and away.” Some of the fatal errors that happened in the home involved young children who took medicines that had been taken out of their normal, secure storage locations. These medicines were no longer locked up because an adult had removed them to either take a dose or give a dose to a family member. In fact, most accidental poisonings in children occur after the medicine has been removed from its normal storage location.5 This often happens within 1 to 15 minutes after the last correct dose of medicine was taken or given, but before the medicine was put back into its normal storage location. Prescription pain medicines (opioids) caused most of the deaths in this category. A description of one of these errors is provided below.
A young child died after drinking some of her father’s liquid methadone dose. Methadone is similar to the opioid pain reliever morphine and can be used either to treat pain or a heroin addiction. The child’s father had mixed the liquid methadone with orange juice in a cup but only finished about half of it. The remaining orange juice in the cup was within reach of the child. The child was seen that evening drinking what appeared to be orange juice. The following morning, the child could not be awakened and later died in the hospital from a methadone overdose.
III. Myths related to the signs of an overdose
In many of the errors studied, caregivers or family members did not know or recognize the warning signs of an overdose or another type of medicine error. This prevented them from quickly recognizing trouble and seeking help, which could have prevented further harm or death. Common myths associated with these types of errors follow.
“They’re asleep, so they must be fine.” In numerous fatal errors, family members or caregivers thought the person was sleeping when, in fact, he or she was unconscious. If unconsciousness is detected right away, there may be an opportunity to save the person. Also, many caregivers or family members recalled hearing the person snore or make gurgling or groaning noises. But they did not know that unusual and irregular snoring is often a sign of a dangerous overdose. In the errors analyzed, family members or caregivers had not tried to awaken the person until it was too late, assuming that “sleep is good,” as in the following example.
A man died from an accidental overdose of extended-release oxycodone (Oxycontin and other brands). Oxycodone is an opioid used to treat moderate to severe pain. The man had previously been taking morphine, which had been prescribed by his family physician. But he was later started on oxycodone after being seen by a pain specialist. The family physician misunderstood the recommendation from the pain specialist and prescribed a very high dose of oxycodone. The man took the high doses of oxycodone for 3 days. The next day, family members did not awaken the sleeping (but really unconscious) man to take his medicine. Two hours later, the family found the man dead.
“Most side effects from medicines will resolve by themselves.” With some of the errors, there was a notable side effect or change in the person’s behavior, which could signal a medicine overdose. There are many medicines used to treat a variety of conditions that can cause side effects or irregular behavior if given too frequently or at a higher dose than prescribed. In the errors that were analyzed, family members did not recognize the seriousness of the side effects or behavior change prior to death. An example follows.
A man with a history of mental illness and chronic pain was found dead at home. He had just been started on a new opioid medicine to treat the pain. Two days before he died, a family member noticed that the man was very groggy and “did not seem like himself.” The family member thought these effects were due to the change in the pain medicine, but that they would resolve once he got used to the new medicine. The patient’s death was caused by an overdose of the opioid pain medicine. The overdose was thought to be accidental.
IV. Myth related to seeking help after a medication error
Harm or death can often be lessened or prevented even after errors have happened—but only if the person reports the error to a healthcare professional and seeks medical advice or attention.
“Medication errors thought to be insignificant can be ignored.” In some instances, consumers, family members, or caregivers were aware that an error had happened but did not seek help because they thought it was harmless, especially if the person did not have immediate signs of any problems. The following event illustrates a reluctance to seek help, even when an error was known to have occurred.
A man lived in a communal home for people with mental health issues. The owner of the home was responsible for giving any needed medicines to the tenants at mealtimes. On the day of the error, the owner was ill and asked a family member to give the medicines to the tenants. One of the men in the house accidentally received someone else’s medicines, including several powerful antipsychotic medicines: quetiapine (Seroquel), loxapine (Adasuve), and olanzapine (Zyprexa). When the family member realized the error, he immediately notified the owner of the house. The owner of the house thought the medicines the man had received were not significant enough to warrant medical attention. However, these medicines can have serious side effects involving the heart, blood pressure, and breathing. The man went to bed that evening and was found dead in his room the following morning.
Deadly medicine errors that happen in the home are often caused by misbeliefs about how medicines work, their side effects, signs of an overdose, how to prevent childhood poisonings, and when to call for medical help. Based on the study conducted on deadly errors in the home, recommendations to improve medicine safety in the home can be found to the right of this article.
1.National Center for Health Statistics. Therapeutic drug use: prescription drug use (2009-2012). http://www.cdc.gov/nchs/fastats/drug-use-therapeutic.htm
2.Consumer Healthcare Products Association (CHPA). The value of OTC medicine to the United States. January 2012. www.chpa.org/ValueofOTCMeds2012.aspx
3.Kotz D. Overmedication: are Americans taking too many drugs? US News, Health. October 7, 2010. www.ismp.org/sc?id=302
4.ISMP Canada. Deaths associated with medication incidents occurring outside regulated healthcare facilities. ISMP Can Saf Bull. 2014;14(2):1-6.
5.Ferguson RW, Samuel E. Keeping families safe around medicine. Washington, DC: Safe Kids Worldwide; March 2014. www.safekids.org/med_report_2014