Prescription Errors — When Can Medication Kill?

After hospitalization, Mr. Jones was prescribed a blood-thinning medication called Coumadin. He picked up his new prescription at the neighborhood pharmacy on the way home. When he opened his new prescription, a slew of papers spilled from the envelope. Annoyed, he threw them in the trash, not noticing the prescription strength was different from what his doctor had ordered. The next morning, his wife found him dead on the bathroom floor. Mr. Jones had slipped, hit his head on the sink, and died from a brain hemorrhage due to his blood not clotting properly. The pharmacy had incorrectly filled his prescription, dispensing double the dose of blood-thinning medication prescribed.

Mr. Jones’ death was totally preventable, but he and more than 1.5 million people every year are harmed due to medication errors according to a report by the Institute of Medicine. The cost of death and injury from such medication errors has been estimated to be $77 billion dollars annually (Preventing Medication Errors, National Academies Press: 2007:124-5).

Common types of medication errors include the wrong medication being prescribed due to an incorrect diagnosis, poor drug distribution practices, inadequate communication to the patient, and dispensing errors (e.g., incorrect medication, dosage strength, or dosage form; miscalculating a dose; and failing to identify drug interactions or contraindications).

When are you most vulnerable to falling victim to a medication error?

Certain conditions in hospital and community pharmacies create a risk for medication errors. Among the top reasons for medication errors are disorganized work flow, fatigued staff, frequent interruptions and distractions, poor physician handwriting, an emphasis on volume over service quality, stress, ineffective communication with patients, improper technician training and inadequate staffing (National Association of Pharmacy Regulatory Authority).

Despite new technology, such as bar scans on medications, electronic medical records, automated medication dispensing and e-prescribing, medication errors still occur because pharmacists and technicians can override these systems.

How can you prevent prescription errors from happening to you?

Be watchful about the medications you receive, and ask questions. Begin by making a list of all medications you currently are taking. Type this list, make several copies and give it to any nurse or doctor when they ask what medications you are taking. Also, look at your pills before you place them in your mouth. If they do not look the same as your last prescription, ask your pharmacist why.

As a nurse, I was taught the “Five Rights of Medication Administration”:

  1. Was the RIGHT drug ordered?
  2. Did the RIGHT patient receive the medication?
  3. Was the drug given by the RIGHT route (e.g., orally, intravenously or injection)?
  4. Was the RIGHT dosage given?
  5. Was the medication provided at the RIGHT frequency (i.e., three per day)?

If you follow these tips, you may save yourself or a loved one from a dangerous medication error.