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Medication Error (PDF)


									  Special Report – Protect Yourself From Medication Errors

Prescription errors continue to be on peoples minds and often make
national headlines. Medication errors can happen in hospitals,
pharmacies, doctors offices, nursing homes, and your home. In fact,
medication errors can occur anywhere drugs are prescribed or
dispensed and can occur at any time.

Medication Error Definition
Here is the definition of a medication error provided by The National
Coordinating Council for Medication Error Reporting and Prevention

     A medication error is "any preventable event that may cause or
     lead to inappropriate medication use or patient harm while the
     medication is in the control of the health care professional,
     patient, or consumer. Such events may be related to professional
     practice, health care products, procedures, and systems,
     including prescribing; order communication; product labeling,
     packaging, and nomenclature; compounding; dispensing;
     distribution; administration; education; monitoring; and use."

As you can see, a medication error can occur at any time and can
involve anyone in the process of getting the correct medication to the
intended person. Everyone involved in the process also has a
responsibility to try to prevent an error from happening. Yearly,
community pharmacies dispense over 3 billion prescriptions. It is
estimated the error rate in the dispensing process is between 0.26%

   Special Report – Protect Yourself From Medication Errors

and 24%. Many of these errors are significant enough to cause harm.

The Institute of Medicine published a report in 2006 estimating there to
be at least 1.5 million adverse drug events in the United States every
year. This number includes all settings such as hospitals and long term
care facilities. They state the true number may be even higher.

To combat medication errors all the medical professions are working
on ways to reduce errors in their respective environments. In order for
these efforts to be effective the Institute of Medicine states a
comprehensive approach is required to prevent errors from happening.
There will need to be changes from doctors, nurses, pharmacists,
other health professionals, the Food and Drug Administration, other
government agencies and from patients.

You, the patient or caregiver, need to be directly involved in preventing
errors and there are lots of things you can do to take an active role.

Here are the 6 major tips promoted by the FDA
   ●   Know the names of your medications - Ask the doctor the drug
       name when he writes a prescription so you can tell if you are
       given something different when you get the prescription filled.
       Many people just accept the prescription from the doctor without
       knowing which medication was prescribed. If you don't know
       which medication the doctor prescribes, you won't be able tell if
       the pharmacy fills it incorrectly.
   ●   Ask questions - How do I take this? What can I expect? What if I

Special Report – Protect Yourself From Medication Errors

    miss a dose? What side effects are possible? All these
    questions help you to understand your medications. By knowing
    about the medication you are more likely to notice if a mistake is
●   Know what the medication is for - By knowing what your
    medication is used for you are more likely to understand how to
    take it, what to expect from the medication, and you will be better
    able to report if you are having problems with it.
●   Read the medication's labels and follow the directions - Before
    you use a medication you should know when to use it, how much
    to take, how frequently and for how long. Read the label every
    time. There are many reports of people taking the wrong
    medicine in the middle of the night because they did not turn on
    the light to read the label. Also, reading the label ensures you are
    getting the correct dose. Don't trust your memory for the correct
    dose, many people have taken the wrong quantity by trusting
    their memory.
●   Tell all your healthcare providers all of your medications - You
    should keep an up to date list of the medications you take. This
    should include prescriptions, over the counter medications,
    vitamins and herbal/natural products. They cannot make an
    informed review without complete information. The easiest way
    to do this is to download this universal medication form and use
    it according to the instructions.
●   Keep this list with you - You should have this list with you at all

   Special Report – Protect Yourself From Medication Errors

       times and let a loved one know where you keep it. You should
       also have a copy at home.

Follow these tips from the FDA and you are less likely to encounter
medication errors. But there are other steps you can take to prevent
errors that go beyond the FDA's suggestions. Here are some
additional tips from PharmerDon. These come from many years of
experience working as a pharmacist as well as education and research
related specifically to medication errors.

Additional Tips from PharmerDon
   ●   When the doctor writes a prescription, make sure you can read
       it. The prescription should be clearly written with no
       abbreviations which are often misinterpreted. A type written or
       computer generated prescription is even better. Many people
       joke about doctor's poor handwriting but this is not a laughing
       matter. Many mistakes have happened due to illegible
       handwriting. Do not tolerate poor handwriting on your
       prescription. Your life may depend on it.

   ●   Avoid letting the doctor's office call the prescription in to the
       pharmacy. There is less chance of an error if you bring the
       prescription to the pharmacy or the doctor sends it electronically.
       The person calling in the prescription sometimes is not familiar
       with the correct pronunciation and may say it in a way that
       sounds like a different medication. Another way a mistake can be

Special Report – Protect Yourself From Medication Errors

    made is when the person phoning in the prescription is in a hurry
    and rushes through the phone call.

●   Stay with one pharmacy for all of your prescriptions. If all your
    medicines are on file in one location the pharmacist can screen
    for interactions and other problems. With fierce competition
    between pharmacies it is tempting to get some $4.00
    medications in one location, free antibiotics in another and move
    from pharmacy to pharmacy in search of the latest gift card
    promotion. This practice could set you up for potential problems
    such as drug interactions and overlapping therapy when your
    pharmacies are not aware of your complete medication list.

●   Avoid transferring your prescriptions from one pharmacy to
    another. I have seen errors occur when a prescription is
    transferred between pharmacies. Some people pharmacy hop
    because of the “free gift card” when you transfer a prescription.
    The more a prescription is moved around the greater the chance
    for a mistake. If you must transfer a prescription due to traveling,
    bring in the prescription bottle from the sending pharmacy and
    give it to the receiving (filling) pharmacy. This decreases the
    chance of a mistake during the transfer.

●   Periodically (about every 6 to 12 months) ask your doctor to
    review your medications. Ask if there are any that can be
    stopped or if there are potential problems. You can ask your
    pharmacy to do the same.

Special Report – Protect Yourself From Medication Errors

●   Take an active role in understanding your medicine and
    managing your condition. The more you know about your
    medicine and your condition the more likely you will receive
    appropriate therapy and the lower the chance of an error getting
    past you.

●   Be aware some medications are available in more than one
    dosage form (such as tablet, capsule, plain, extended release)
    and verify you are receiving the correct one. This is a very
    common source of mistakes. I have seen tablets given when a
    suppository is ordered or an immediate release medication
    prescribed when an extended release medication was needed.

●   Always verify the medication you received from the pharmacy is
    the same the doctor wrote on the prescription. For refills verify
    the medication looks the same as the previous time. Question
    any differences you notice.

●   Always keep medications in the original container with the
    pharmacy label on it. The label identifies the medication and
    provides dosing information. Combining all your medications into
    one bottle for convenience increases the chances of taking the
    wrong medication.

●   Don't take someone else's medications. It may not be right for
    you or it may interact with your other medications.

  Special Report – Protect Yourself From Medication Errors

Remember, everyone is human and capable of errors. No one wants to
make a mistake but it only takes a brief lapse of concentration for
someone to make a potentially serious mistake. Do your part, be
involved and ask questions. You are the last one involved in the
medication administration process. Be confident the medication you
are taking is the correct one for you.

Follow these basic principles of medication therapy. Double check
every time to make sure you have:

   ●   The right medication

   ●   For the right person

   ●   In the right amount

   ●   At the right time

   ●   By the correct route (swallow, chew, apply etc.)

With the large number of medications the average person uses each
year, the chance of being involved in a medication error in your lifetime
is quite high. Follow these guidelines and stay alert to ensure
medication safety for you and you family.

You can get more information about medication safety at and at ISMP

Keep a record of all your medications by using a Universal Medication
Form this link is to the best one I have ever seen.

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