Medication Errors - Common

By Connect with Kids

“I’m looking at it, and I’m about to give it to her, and I notice that it says 1½ teaspoons and I clearly remember the doctor telling me it was 1 teaspoon … so I’m looking at the label and I realize it’s not our name.”

– Janet Smith, mother

When we take a child to the doctor’s office or pick up a prescription at the pharmacy, how likely is it that a doctor, nurse or pharmacy will make a mistake -- one that could harm our child? The author of a new study says it’s more common than people believe.

Janet Smith is very careful about giving medicine to her children, and for good reason …

“I thought I had poisoned her,” recalls Smith.

When Smith’s daughter Katelyn was 2, the pediatrician prescribed a common antibiotic for her ear infection. Smith had given her daughter one dose when she realized the pharmacy had given her the wrong medication!

“I’m looking at it, and I’m about to give it to her, and I notice that it says 1½ teaspoons and I clearly remember the doctor telling me it was 1 teaspoon,” says Smith. “So that caused me to say, ‘something’s not right here,’ so I’m looking at the label and I realize it’s not our name.”

It turns out that medication mistakes are not uncommon.

A new study in the journal, Pediatrics, studied children in the hospital. The study found that 1 in 15 pediatric patients is harmed by medicine errors, overdoses and bad reactions. The study also found that more than half of the problems were related to painkillers.

“I think the average American thinks doctors are infallible; we trust them and we trust our pharmacist, and both are human, both makes mistakes,” says Julie Wickman, pharmacist and pharmacy professor.

Now, when it comes to medicine and her kids, Smith double checks everything.

“When I get medication, when I get a prescription, I listen very carefully to what the doctor says,” says Smith. “I question what the doctor is writing, what it’s for, and when I get the drug home I check the leaflet with the label with what the doctor told me.”

Experts say be thorough, be careful, know what the doctor prescribes, and make sure that’s exactly what you get.

“I trust doctors. I trust them, but I am also very cautious,” says Smith.

Tips for Parents
The American Hospital Association lists the following as common types of medication errors:

Incomplete patient information (not knowing about patients' allergies, other medicines they are taking, previous diagnoses, and lab results, for example)
Unavailable drug information (such as lack of up-to-date warnings)
Miscommunication of drug orders, which can involve poor handwriting, confusion between drugs with similar names, misuse of zeroes and decimal points, confusion of metric and other dosing units, and inappropriate abbreviations
Lack of appropriate labeling as a drug is prepared and repackaged into smaller units
Environmental factors, such as lighting, heat, noise, and interruptions that can distract health professionals from their medical tasks
What You Can Do (Institute for Safe Medication Practices, ISMP)

In one case reported to the Institute for Safe Medication Practices (ISMP), a doctor called in a prescription for the antibiotic Noroxin for a patient with a bladder infection. But the pharmacist thought the order was for Neurontin, a medication used to treat seizures. The good news is that the patient read the medication leaflet stapled to his medication bag, noticed the drug he received is used to treat seizures, and then asked about it. ISMP president Michael Cohen, R.Ph., Sc.D., says, "You should expect to count on the health system to keep you safe, but there are also steps you can take to look out for yourself and your family."

Know what kinds of errors occur. The FDA found that the most common types of errors involved administering an improper dose (41 percent), giving the wrong drug (16 percent), and using the wrong method of administration (16 percent). Older people are especially at risk for errors because they often take multiple medications. Children are also vulnerable because drugs are often dosed based on their weight, and accurate calculations are critical.

Find out what drug you're taking and what it's for. Rather than simply letting the doctor write you a prescription and send you on your way, be sure to ask the name of the drug. Cohen says, "I would also ask the doctor to put the purpose of the prescription on the order." This serves as a check in case there is some confusion about the drug name. If you're in the hospital, ask (or have a friend or family member ask) what drugs you are being given and why.

Find out how to take the drug and make sure you understand the directions. If you are told to take a medicine three times a day, does that mean eight hours apart exactly or at mealtimes? Should the medicine be stored at room temperature or in the refrigerator? Are there any medications, beverages, or foods you should avoid? Also, ask about what medication side effects you might expect and what you should do about them.

Read the bottle's label every time you take a drug to avoid mistakes. In the middle of the night, you could mistake ear drops for eye drops, or accidentally give your older child's medication to the baby if you're not careful.

Use the measuring device that comes with the medicine, not spoons from the kitchen drawer. If you take multiple medications and have trouble keeping them straight, ask your doctor or pharmacist about compliance aids, such as containers with sections for daily doses.

Keep a list of all medications, including over-the-counter (OTC) drugs, as well as dietary supplements, medicinal herbs and other substances you take for health reasons, and report them to your health care providers. Remember to tell your doctor if you are taking any vitamins, laxatives, sleeping aids, and birth control pills as they can have negative interactions with other medications. For example, some antibiotics can lower the effectiveness of birth control pills. If you see different doctors, it's important that they all know what you are taking. If possible, get all your prescriptions filled at the same pharmacy so that all of your records are in one place. Also, make sure your doctors and pharmacy know about your medication allergies or other unpleasant drug reactions you may have experienced.

If in doubt, ask, ask, ask. Be on the lookout for clues of a problem, such as if your pills look different than normal or if you notice a different drug name or different directions than what you thought. Robert Krawisz of the National Patient Safety Foundation says it's best to be cautious and ask questions if you're unsure about anything. "If you forget, don't hesitate to call your doctor or pharmacist when you get home," he says. "It can't hurt to ask."

References
American Hospital Association
National Patient Safety Foundation
Institute for Safe Medication Practices, ISMP)