Medication Mistakes Are Common And Deadly

Millions of people are apprehensive about flying. It’s more dangerous to drive to the airport than it is to fly across the country, but a lot of folks worry that there could be a plane crash.
Imagine their consternation if the flight attendant announced before takeoff that pilot error was common and that passengers might suffer serious injuries or even death before arriving at the destination.
Fortunately, you never hear such announcements. The airlines have multiple systems in place to counteract pilot error and keep passengers safe.
The same cannot be said for hospitalization. Five years ago the Institute of Medicine (IOM) rocked the medical community with its report, “To Err is Human.” The authors estimated almost 100,000 Americans die each year due to medical errors, many of them preventable.
Even more alarming, an analysis last year showed that the IOM probably underestimated. The actual hospital death toll from errors is closer to 200,000.
A recent update (JAMA, May 18, 2005) concludes that: “progress is frustratingly slow. Building a culture of safety is proving to be an immense task and the barriers are formidable.”
Medication mistakes have turned out to be one of the most prevalent problems. Any pharmacist could tell you that it is not uncommon for a patient to receive the wrong medicine, the wrong dose or a combination of medications that are incompatible.
One survey found that community pharmacies make mistakes on roughly two percent of the prescriptions they dispense. That may not seem serious, but when you consider that around three billion prescriptions are filled each year, it comes to over 50 million mistakes.
Such big numbers are hard to grasp. Although many errors are so trivial they do no harm, others cause great suffering or even death.
In one classic case, a 67-year-old woman was mistakenly dispensed the diabetes drug glyburide instead of her blood pressure medicine metoprolol. When her blood sugar levels dropped dangerously low, doctors were mystified. She could easily have died. The doctor who reported the case noted: “If the patient’s husband had found her dead on the floor at their home, the dispensing error would have gone unrecognized. Because of the patient’s history of hypertension and acute myocardial infarction, her death would most likely have been reported to be due to a ‘heart attack.'”
To prevent such dangerous medication misadventures, every patient must guard against mistakes. Instead of grabbing your prescription bag and heading out of the drugstore as fast as possible, take a moment to read the label and examine your pills. If it is a medicine you take regularly, ask the pharmacist about any change in the appearance of the pills.
It helps to have the label indicate the use of the medicine. One pharmacist told us this story: “A patient picked up his medications and returned immediately from the parking lot. He objected, ‘This bottle says to take 1 teaspoonful 4 times a day for cough. I don’t have a cough.'”
It turned out the customer’s prescription was meant for someone else. Being an alert patient, whether in the hospital or in the community drugstore, could save your life.