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Reporting a Medication Error

Good Catches – Know What to Expect and Where to Look

Published January 11, 2023

We all know mistakes can happen, including errors with medicines. When mistakes do happen, it is important to report them so we can learn from them. Many reports we receive describe a “good catch” – when a person (or their caregiver, family member, or friend) notices something is not right. By saying something to the doctor, pharmacist, or nurse, you may prevent the error from happening. There are two important steps in identifying errors: knowing what to expect when taking the medicine and knowing where to look for information about the medicine.

Knowing what to expect

It is important for you to know what medicines the doctor prescribed (including the name and dose) for you, what the medicine looks like, and how the medicine should make you feel. For example, if a doctor prescribes a medicine to treat high blood pressure, you may feel a little tired. But if you feel overly tired or weak, that could be a sign the dose of medicine is too high. This is exactly what happened in the report below:

A doctor prescribed a medicine to lower a person’s blood pressure. After a few weeks, the doctor increased the dose from 4 mg to 8 mg per day. After taking the new dose for a few days, the person felt more tired and had very little energy. They knew the medicine should not make them feel this way. The person looked at the label on the prescription bottle and noticed that the dose of medicine was 16 mg instead of 8 mg that the doctor had prescribed.

Knowing where to look

It is also important for people to know where to find information about the medicines they are taking. Places you can look for information include the prescription label on the medicine bottle, the drug information sheet (medication guide) that the pharmacist provides with the medicine, the product packaging, and online. Read the case below as an example of where to look for drug information.

A consumer listed an allergy to penicillin on the medical form prior to a dental procedure, but listed it in the wrong area on the form. The dentist missed the reported allergy and prescribed amoxicillin for the person after the procedure. The pharmacist also missed the allergy when preparing and dispensing the medicine to the person. At home, the person read the information sheet they received from the pharmacy and noticed that amoxicillin is similar to penicillin. After searching the internet for more information, they learned that anyone with an allergy to penicillin should not take amoxicillin.

Here’s what you can do: People should know what to expect and where to look for information about the medicines they take. Consider the following recommendations before taking medicines:

  • Ask questions. Use the “5 Questions to Ask” model (www.ismp.org/ext/1045) to help you know what to expect about medicines prescribed for you.
  • Know what medicines you take. Learn the names and doses of the medicines that your doctor prescribed for you and why you need to take them.
  • Know what your medicines look like. Be familiar with what your medicines look like, including the size, shape, color, and markings on the medicine itself and the container. If they are not what you expect, ask your pharmacist. It may be that the medicine is the same as before but from a different company.
  • Be aware of the side effects – both good and bad. Knowing how you should feel after taking the medicine can help you make sure the medicine is working. It can also help you watch out for side effects, in case something unexpected happens.
  • Read the prescription bottle label. Check the label to verify your name, the name of the medicine, the strength or dose, and the directions for use. Be sure you understand any warning labels that the pharmacist added to the bottle.
  • Read the product packaging. Sometimes the pharmacist will dispense the medicine in its original bottle or carton from the company. Reading the information on the bottle or carton can help you understand more about the medicine.
  • Search for information online. If you have questions or concerns about the medicine, you can search trustworthy websites such as: this website, www.medlineplus.gov, or www.fda.gov.
  • Contact your health care team. Do not hesitate to call your doctor or pharmacist if you have any questions or concerns about your medicine.

We would like to thank our sister organization, ISMP Canada, for providing information for this article.

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