Arm Patients With Information to Uncover Errors

Michael J. Gaunt, PharmD
Published Online: Thursday, August 16, 2012
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Much can be learned from cases in which patients are the ones to discover mistakes made with their medications.

Patients should be advised that medication errors can occur and that they can play a role in preventing these errors. The patient is the final link in the medication-use process. As such, an alert and knowledgeable patient can serve as the last line of defense in preventing medication errors. Thus, to prevent errors, patients must receive ongoing education by physicians, pharmacists, and nurses about their medications and ways to protect themselves from errors.

Below are 2 cases in which patients, armed with crucial drug information, were able to intercept an error. Included are suggested risk-reduction strategies for each situation.

Case 1: E-Prescribing Best Practices

A health care consumer reported an error after the pediatrician sent a prescription to a community pharmacy for her 11-year-old daughter. The prescription was for MIRALAX powder (polyethylene glycol 3350), and the dose was 3 TEAspoonfuls by mouth mixed with 6 ounces of liquid, to be taken once a day for 30 days. However, the label on the bottle the patient received stated 3 TABLEspoonfuls to be mixed daily for 30 days.

Although the physician sent the prescription electronically, he gave the patient’s parents a hard copy of the prescription in case there was a problem filling it. Had she not received the backup prescription, the patient’s mother told us that she would not have known the correct dosage and would have given her daughter more than the required dosage for her age and weight. She said she was very thankful that she read and noticed the error.

Electronic Should Not Equal Paperless
Patients should always receive verbal instructions from the prescriber and be given an opportunity to ask questions. With e-prescribing, they should also be provided with a clearly marked copy or some sort of corresponding “voucher” that lists the prescribed medication, dose, and directions for use. Ideally, e-prescribing systems should automatically provide a voucher when the e-Rx is transmitted so that the prescriber does not have to remember to print one separately. The patient can use the voucher to check the prescription by matching it to what he or she actually receives in the pharmacy to ensure it is the correct medication.

Case 2: Intercepting Dispensing Mistakes
A patient recently reported to the Institute for Safe Medication Practices that she used the tablet description printed on the pharmacy-generated label to discover a dispensing error. When she arrived home after picking up a prescription for her blood pressure medication, she read the tablet description on the label before taking a dose of the medication.

Immediately, she saw that the description did not match the appearance of the tablets in the bottle. She called the pharmacy to question why the mismatch occurred and learned that instead of 25-mg tablets of atenolol as prescribed, she received tablets that were actually 50 mg. That strength had caused side effects in the past, so she returned it and got the correct strength.

Double-Check by Comparing Label and Product
In theory, patients can receive differentlooking tablets or capsules every time they refill their prescription when generics are dispensed. With such wide variation in a single medication’s appearance, and with constant interchanging of products due to drug shortages and generic equivalents, both patients and health care practitioners have become somewhat complacent about double-checking when the tablet, capsule, or liquid looks different. Often they simply assume that the differences are the result of a different manufacturer’s product being used. As a result, appearance no longer serves as an effective passive control feature.

All pharmacies should emphasize the safety features of adding a visible tablet, capsule, or liquid description to their labels. Even if the generic manufacturer is different each time the prescription is renewed, the description will help patients to quickly determine if the medication in the bottle matches the description on the label.


Dr. Gaunt is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/ Ambulatory Care Edition.


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