Medication Safety Articles

 

Companies often use color on products to capture attention or differentiate items. For instance, bright colors may draw your attention to a specific word or detail on a label. Companies also use color to distinguish different products within their brand.

A doctor prescribed Donnatal (hyoscyamine, atropine, scopolamine, and phenobarbital) for a man who was allergic to one of its ingredients, phenobarbital. Donnatal is used to relax the muscles in the bladder and intestines and to reduce stomach acid. The community pharmacy’s computer system issued a warning about the allergy, but the pharmacist missed seeing the message while entering the prescription into the computer. The doctor also overlooked the allergy even though it was documented in the patient’s chart. The error was discovered by the man while reading the pharmacy provided consumer medication information leaflet, which listed phenobarbital as one of the ingredients. The man did not take the Donnatal.

Our organization received a report from the Food and Drug Administration (FDA) about a mix-up involving a vaginal ring. The mix-up involved two medications that can both be delivered by a vaginal ring. The medication prescribed was NuvaRing (etonogestrel/ethinyl estradiol) but the doctor actually intended to prescribe Estring (estradiol). Vaginal rings release medicine over an extended period of time by inserting a plastic ring shaped device into the vagina (see photo).

Families take medications and vitamins to feel well and to stay well. But did you know that more than 60,000 young children end up in emergency rooms every year because they get into medicines when their parent or caregiver isn’t looking?

With millions of Americans suffering from diabetes, there has been tremendous growth in the use of insulin. For convenience, many insulin dependent diabetics carry their insulin in a prefilled syringe available from drug manufacturers. The device is called an insulin pen because it looks similar to a writing pen and can be carried in your pocket. An insulin pen is designed to give multiple injections of insulin after changing the single use attachable needle.

Patients who keep an EpiPen on hand in case of a severe allergic attack need to know about a potentially dangerous mix-up between the actual pen and a similar looking training pen.

An American man who took Dilacor XR (diltiazem extended-release) ran out of medicine while traveling to Serbia. A Serbian pharmacist refilled the prescription with a brand name medicine called Dilacor. But in Serbia, Dilacor is the brand name for digoxin, a totally different medicine than diltiazem.

Several mix-ups between the medications INVEGA (paliperidone), which is used to treat schizophrenia, and INTUNIV (guanFACINE), used to treat attention deficit hyperactivity disorder (ADHD) have been reported to us.

Recently we wrote about the tragic death of a 2-year-old child due to an accidental overdose of fentanyl after putting a used patch in his mouth. This was not the first time we wrote about a young child unintentionally gaining access to a powerful medicine. For this reason, we have often emphasized the importance of keeping all medicines up and away and out of reach of young children. But what about older children and teenagers?

Many people are aware that prescription pills, tablets and capsules have unique letters and numbers on them used for pill identification. With each new prescription, it’s important to check the pill identification to ensure you have the correct medicine. Most people only complete this safety check when they first get a new prescription. However, every time you take a pill, you should make sure it is correct.

Medication Safety Alerts

FDA Safety Alerts

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