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| The Last Line of Defense Against Medication Errors:
What You Need to Know to Keep your Family Safe Copyright 2004, Timothy
McNamara, MD, MPH |
| 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 |
| Timothy McNamara, MD, MPH is a nationally prominent
expert in medication safety and healthcare technology. For additional
practical steps you can take to improve medication safety and a personalized
report of your medication profile, go to: <http://www.medicationadvisor.com/art1.asp>
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