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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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