Published June 15, 2020 (current as of June 20, 2024)
Consumers can often spot a medication error by knowing what to expect. This includes knowing what medicine has been prescribed (for example, the name and dose), what the medicine looks like, and what side effects to expect. The following reported error and great catch shows the importance of knowing about the medicine you take.
A consumer was started on a medicine to control his blood pressure. The dose was later increased from 4 mg to 8 mg per day. After taking the new dose for a few days, the consumer felt overly tired and had low energy. The consumer’s blood pressure reading had also dropped by 40 points. Knowing these were potential side effects of the medicine, the consumer read the label on the prescription bottle and noticed that the strength of the medicine was 16 mg, not the 8 mg that had been prescribed. The consumer contacted his healthcare provider.
Here’s what you can do: While dispensing errors happen infrequently, consumers are the last line of defense and should speak up if something does not seem right. Here are the top 10 reasons to suspect a medication error:
The medicine’s appearance (color, shape, markings on the tablet) is different from expected, and the pharmacist did not warn the person about switching to a different manufacturer.
The smell or taste is different than expected or extremely unpleasant.
The amount of liquid in a syringe or bottle is more or less than expected.
The number of tablets or capsules in a prescription bottle is more or less than expected.
The directions on a prescription bottle label differ from what your doctor told you.
The patient’s name on the label is not as it should appear, including misspellings or incorrect suffixes like Jr. or Sr. if others in your household have the same name.
The doctor’s name on the label is not your doctor.
The name of the medicine on the bottle label is not as expected.
The reason for taking the medicine (in a leaflet or mentioned by the pharmacist) is different from the condition being treated.
After renewing a prescription, you experience new side effects or begin to notice physical changes after taking a few doses, such as a change in urine color, unexpected weakness or drowsiness, dizziness, breathing difficulties, racing heart, vision problems, and so on.
Do you use an inhaler? If so, always replace its cap after use. The importance of replacing caps on inhalers was recently illustrated when a woman accidentally inhaled a small earring while using her asthma medicine. She got her uncapped inhaler from her purse. As she inhaled the medicine, she felt a painful scratch in her throat and started coughing blood. She was taken to the emergency department, where the earring was removed from her lung. If the inhaler's cap had been in place, the loose earring in her purse would not have gotten into the inhaler.
Confusion between the medicines Wakix (pitolisant) and Lasix (furosemide) was reported. Wakix is used to treat adults with narcolepsy (sleep disorder) for excessive daytime sleepiness. Lasix is a diuretic (or “water pill”) which increases the flow of urine to rid the body of excess fluid and salt. Using an online secure messaging system, a man was asking his doctor about a change in his dose of “Wakix” and whether he should get blood tests drawn. The man was also taking Lasix, and the dose had been changed several times over the years. The man had made several spelling errors when typing messages to his doctor. The doctor assumed the man had made a spelling error when typing “Wakix” and was instead talking about Lasix. Further questioning revealed the man actually was asking about Wakix.
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