Medication Safety Articles


There are some asthma medications that come as powder-filled capsules. The powder inside though is meant to be breathed into the lungs using a special device called an inhaler.

Fentanyl is a very powerful pain reliever. It is only supposed to be prescribed for people with long-term (chronic) pain who have already been taking high doses of prescription opioid (narcotic) pain medicine for at least a week. Serious harm or death has resulted when this drug was taken in high doses by people who have not been taking other prescription opioid pain medicine for 7 days or more.

A pharmacy accidentally dispensed Carac (fluorouracil) cream (0.5%) instead of Kuric (ketoconazole) cream (2%). These products have similar-sounding names. The pharmacist thought the doctor said 'Carac' not 'Kuric,' when he listened to the doctor's voicemail message. Carac cream is used to treat pre-cancerous skin lesions of the face and scalp.

Metoprolol succinate extended-release tablets have been in short supply lately. This is a generic heart and blood pressure medicine used by many consumers. The companies that make this medicine had stopped producing it because of problems with the quality of the tablets. Although the problem is beginning to resolve, the medicine may not be available when consumers try to fill or refill their prescriptions.

You may have seen some advertisements for testosterone gel products that men can apply to the skin when they have documented low testosterone (male hormone) levels. Restored testosterone may lead to increases in sexual desire, mood and energy.

A nurse caring for a patient who was unable to swallow LOVAZA (omega-3-acid ethyl esters), punched holes in the large, soft gelatin capsule, squeezed the oily yellow liquid contents into a disposable foam plastic cup (often called a Styrofoam cup), and diluted it with cranberry juice. Later, as the patient raised the cup to drink the juice, the cup began to leak.

A consumer contacted us recently after visiting a hospitalized patient. While there, she had the opportunity to observe nurses administering medications. She told us that the nurses would bring a clear plastic cup with loose tablets and capsules into the room, hand the pills to the patient, and ask the patient to swallow them. The person who wrote to us noted that none of the pills were labeled. She wanted to know if this was the proper procedure, since it would be difficult to assure that these unlabeled medications were right for the patient.

Many consumers feel strongly about taking a daily multivitamin. They believe it is one way to maintain a healthy lifestyle. However, consumers must be cautious with multivitamins especially if they are on other medicines. Sometimes other ingredients such as herbals (i.e. Ginkgo biloba, ginseng) are added to multivitamins. These herbals may interact with other medicines you are taking.

Many people have experienced an unpleasant side effect to a medication, such as an upset stomach, diarrhea, or excessive sleepiness. Medication side effects are pretty common and can be expected, especially with certain drugs. For example, people may have nausea when taking a narcotic or diarrhea from an antibiotic. However, it is important to know that these side effects are not allergies because we’ve heard them referred to as such.

Who would ever make that mistake? Well, people do. A father told the babysitter to put his son's ear drops in his right ear before bed, and the careful babysitter did just that. She found ear drops labeled "put two drops in right ear" in the medicine cabinet, and instilled the ear drops into the child's right ear. But the family's dog also had a bottle of ear drops, which were the drops the babysitter used. The son's ear drops were in the refrigerator. Luckily, the child was not harmed by the dog's ear drops.

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