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