Medication Mistakes Are Common And Serious

To err is human, but mistakes are unforgivable when lives are at stake. That’s why pilots go through a comprehensive checklist before takeoff and why copilots are always vigilant for any unexpected problem.
Such backup and fail-safe systems are needed in pharmacies and hospitals, too. For decades, experts have warned of the high rate of errors in prescribing and dispensing medications. But despite the attention from researchers, the situation has been deteriorating.
In 1990 a landmark study discovered mistakes affecting 3 out of every 1,000 hospital prescriptions. A new study published in the Archives of Internal Medicine (Sept 9, 2002) concludes that medication errors are more common today, affecting “nearly 1 of every 5 doses in the typical hospital and skilled nursing facility.”
Many mistakes involved the wrong dose or missed medicine. Far too many were very serious: “more than 40 per day in a typical 300-patient facility.”
This is not just a hospital problem. A study from Auburn University reveals that neighborhood pharmacies are equally susceptible. Dr. Elizabeth Flynn reports that “Dispensing errors are a nationwide problem, occurring at a rate of 2 errors for every 100 prescriptions filled.this translates to over 60 million errors on 3 billion prescriptions filled each year in the US.”
Interactions between two or more drugs may slip through undetected. One reader was alerted to a potential interaction: “You discussed a study of pharmacists handed two prescriptions that, if taken together, were very dangerous or deadly. The idea was to see if the pharmacists warned patients about the interaction or not before filling the prescriptions.
“Amazingly, I had just started taking those very medications together and had not been warned of an interaction risk. My doctor had given me a long-term prescription for the allergy medication the year before and obviously did not bother to check what I was taking before giving me the second prescription. Thanks for saving my life. Today I have a new doctor and am more careful to check for possible interactions myself.”
Older people in nursing homes are especially vulnerable to mistakes. A reader relates the following: “A few years ago my 95-year-old mother was on Glucophage for diabetes. She was losing weight (down to 82 from 100 pounds) and complained of muscle pain, weakness and nausea.
“I read that such symptoms could be caused by Glucophage. I immediately told them I wanted the medicine stopped. Within two weeks she gained several pounds, was more alert and her appetite and good nature returned. Within another month she was herself again. Not long after that I noticed a full-page ad for Glucophage with a warning, ‘Not recommended for people over 80.'”
With mistakes so common, patients have to be as vigilant as copilots. Never accept a prescription without confirming its accuracy. Our Guide to Drugs and Older People and our Drug Safety Questionnaire can help. Please send $2 in check or money order with a long (no. 10) stamped (60 cents), self-addressed envelope: Graedons’ People’s Pharmacy, No.OQH-883, P. O. Box 52027, Durham, NC 27717-2027.