This is a true story.

Yesterday, I picked up a new antibiotic prescription for my 
daughter from my local pharmacy.

(We recently adopted my daughter from India where she had 
recurrent ear infections resulting in severe hearing loss.  And, 
she is about to undergo the second of several planned surgeries 
in order to try to repair the damage.)

Before putting her to sleep, I got the new medication out of the 
bag, glanced at the instructions, and prepared to give her the 
drug according to the instructions on the label.

Just before doing so, I had a quick double-take.

Something seemed to be wrong.  I looked at the instructions 
again, and thought to myself slowly, "What's going on...this 
doesn't seem right."  Then, it hit me that the dose seemed 
awfully high for her.

It took me a minute or two to put the pieces together (it had 
been an unusually tough fight getting her ready for bed, I was 
tired, I was confident in my daughter's physician, and I was 
thinking perhaps less critically that I should have).  And 
then I noticed it.  The label had a stranger's name on it.

After another moment or two, I saw what had really happened.

The medication came in a box.  Each side of the box had a 
different label...one label was for my daughter and one label 
was for a stranger.  And, the stranger's dose was more than 
double what my daughter's surgeon had recommended.

(This error didn't happen in a mom-and-pop pharmacy.  It 
happened in a modern new chain pharmacy whose name you would 
recognize from advertisements on TV.)   

I'm not a surgeon...and I'm not a pediatrician...but I am a 
physician trained in internal medicine and I have spent most 
of the last twelve years writing about, speaking about, and 
developing systems to reduce the frequency of medication error 
and improve the safety of pharmacy practice.

This pharmacy error brought the topic of drug safety home to 
me...literally.

What I can tell you is that this sort of error occurs all too 
often in the United States (and around the world).  And, that 
it can have devastating consequences for the people involved.

A recent study in the New England Journal of Medicine indicated 
that 25% of patients who take one or more prescription 
medications will experience an adverse drug event within three 
months-and 39% of these are preventable or avoidable.

The Harvard Medical Practice Study found reported in JAMA in 
2001 that 30% of patients with drug-related injuries died or 
were disabled for more than 6 months.

And, what almost everyone who studies this problem agrees is that
current systems for selecting drugs, dosing them, communicating 
a prescription to a pharmacy, dispensing drugs, and instructing 
patients on their safe use are woefully inadequate.

In this series, we are going to take a close look at the 
processes that cause medication errors (some things that your 
physician and pharmacist may not even want you to know) and what 
steps you can specifically take to make sure that you and your 
love ones are protected from this hazard.

Ten years ago, your ability to get current, objective, reliable 
information on your medications in a quick and easy way was 
practically non-existent.  It probably would have involved a 
trip to the library and required considerable knowledge about 
pharmacology to get the answers.

Today, that's not the case.  There is a host of on-line tools, 
databases, and resources that allow you to learn information 
about medications that even your physician and pharmacist may 
not know.

We're going to talk about them, show you were to go, tell you 
the key things you need to know about medications, expose some 
myths, and let you know the questions you should be asking.  
It's not as hard as it may seem.

In fact, you need to become the final line of defense in the 
battle against medication errors.

Throughout, we are going to give you some key rules that should 
guide your defense.


So, Rule Number 1.  Trust, but verify.  Never assume that the 
medication you have received is the right medication for you or 
that it is dosed correctly for you.  Specifically, you should 
check:

 · the name of the patient on the bottle;
 · the name of the doctor on the bottle;
 · the name of the medication (and cross check it to be sure 
   that it treats a disease or problem you actually have...
   there are lots of look-alike/sound-alike drug names out 
   there);
 · the dose (from an independent source...to make sure that it 
   is a plausible dose for you);
 · the "route"  (to make sure, for example, that eye drops are 
   being prescribed for the eye, and not the mouth, or the 
   ear...amazingly injuries from drug misplacement occur all 
   the time);
 · the expiration date.

We'll talk about some specific resources that will help with 
each of these throughout this series.

The result, we hope, will be the piece of mind to know that you 
and your family are getting your 7 rights:

 · right drug;
 · right patient;
 · right dose;
 · right time;
 · right route;
 · right reason;
 · right documentation.

Right on!

© 2004 Timothy McNamara, MD, MPH