| This is a true story.Yesterday, I picked up a new | | | | almost everyone who studies this problem agrees |
| antibiotic prescription for my daughter from my | | | | is that current systems for selecting drugs, dosing |
| local pharmacy.(We recently adopted my daughter | | | | them, communicating a prescription to a |
| from India where she had recurrent ear infections | | | | pharmacy, dispensing drugs, and instructing |
| resulting in severe hearing loss. And, she is about | | | | patients on their safe use are woefully |
| to undergo the second of several planned | | | | inadequate.In this series, we are going to take a |
| surgeries in order to try to repair the | | | | close look at the processes that cause medication |
| damage.)Before putting her to sleep, I got the | | | | errors (some things that your physician and |
| new medication out of the bag, glanced at the | | | | pharmacist may not even want you to know) |
| instructions, and prepared to give her the drug | | | | and what steps you can specifically take to make |
| according to the instructions on the label.Just | | | | sure that you and your love ones are protected |
| before doing so, I had a quick | | | | from this hazard.Ten years ago, your ability to |
| double-take.Something seemed to be wrong. I | | | | get current, objective, reliable information on your |
| looked at the instructions again, and thought to | | | | medications in a quick and easy way was |
| myself slowly, *What*s going on...this doesn*t | | | | practically non-existent. It probably would have |
| seem right.* Then, it hit me that the dose | | | | involved a trip to the library and required |
| seemed awfully high for her.It took me a minute | | | | considerable knowledge about pharmacology to |
| or two to put the pieces together (it had been an | | | | get the answers.Today, that*s not the case. |
| unusually tough fight getting her ready for bed, I | | | | There is a host of on-line tools, databases, and |
| was tired, I was confident in my daughter*s | | | | resources that allow you to learn information |
| physician, and I was thinking perhaps less critically | | | | about medications that even your physician and |
| that I should have). And then I noticed it. The label | | | | pharmacist may not know.We*re going to talk |
| had a stranger*s name on it.After another | | | | about them, show you were to go, tell you the |
| moment or two, I saw what had really | | | | key things you need to know about medications, |
| happened.The medication came in a box. Each side | | | | expose some myths, and let you know the |
| of the box had a different label...one label was for | | | | questions you should be asking. It*s not as hard |
| my daughter and one label was for a stranger. | | | | as it may seem.In fact, you need to become the |
| And, the stranger*s dose was more than double | | | | final line of defense in the battle against |
| what my daughter*s surgeon had | | | | medication errors.Throughout, we are going to |
| recommended.(This error didn*t happen in a | | | | give you some key rules that should guide your |
| mom-and-pop pharmacy. It happened in a modern | | | | defense.So, Rule Number 1. Trust, but verify. |
| new chain pharmacy whose name you would | | | | Never assume that the medication you have |
| recognize from advertisements on TV.)I*m not a | | | | received is the right medication for you or that it |
| surgeon...and I*m not a pediatrician...but I am a | | | | is dosed correctly for you. Specifically, you should |
| physician trained in internal medicine and I have | | | | check:the name of the patient on the bottle;the |
| spent most of the last twelve years writing | | | | name of the doctor on the bottle;the name of |
| about, speaking about, and developing systems to | | | | the medication (and cross check it to be sure that |
| reduce the frequency of medication error and | | | | it treats a disease or problem you actually have... |
| improve the safety of pharmacy practice.This | | | | there are lots of look-alike/sound-alike drug names |
| pharmacy error brought the topic of drug safety | | | | out there);the dose (from an independent |
| home to me...literally.What I can tell you is that this | | | | source...to make sure that it is a plausible dose for |
| sort of error occurs all too often in the United | | | | you);the *route* (to make sure, for example, |
| States (and around the world). And, that it can | | | | that eye drops are being prescribed for the eye, |
| have devastating consequences for the people | | | | and not the mouth, or the ear...amazingly injuries |
| involved.A recent study in the New England | | | | from drug misplacement occur all the time);the |
| Journal of Medicine indicated that 25% of patients | | | | expiration date.We*ll talk about some specific |
| who take one or more prescription medications | | | | resources that will help with each of these |
| will experience an adverse drug event within three | | | | throughout this series.The result, we hope, will be |
| months-and 39% of these are preventable or | | | | the piece of mind to know that you and your |
| avoidable.The Harvard Medical Practice Study | | | | family are getting your 7 rights:right drug;right |
| found reported in JAMA in 2001 that 30% of | | | | patient;right dose;right time;right route;right |
| patients with drug-related injuries died or were | | | | reason;right documentation.Right on! |
| disabled for more than 6 months.And, what | | | | |