Error at a Health Food Store

 

An elderly woman developed diarrhea after taking antibiotics for an infection. Her doctor suggested eating yogurt, but she didn't like the taste. Her doctor then gave her a prescription for Lactinex (Lactobacillus acidophilus and L. bulgaricus). He told her to get this at a health food store. Lactinex is a harmless dried bacteria used to replace bad bacteria in the digestive tract that cause diarrhea.

The woman went to the health food store and gave the clerk the prescription from the doctor. The clerk found the product and told the woman to take 7 capsules before each meal and at bedtime--a total of 28 pills each day! The prescription actually said to take 1 capsule four times a day. However, the doctor had written the number 1 in a particularly unsafe style for prescriptions, with a bar and dot over a vertical slash mark ( NEED SYMBOL ). Thus, the number 1 looked like the number 7. The woman took 28 capsules the first day. By the next day she had severe nausea, vomiting, and diarrhea, worse than before. She was hospitalized for 24 hours.

If you take a prescription to a health food store, remember that the sales clerks have no knowledge or training to read and interpret prescriptions. So ask your doctor to go over the directions with you. For safety reasons, it would be best to purchase nonprescription products from a pharmacy if possible. This helps your pharmacist know about all medicines you are taking, even those that don't require a prescription. Pharmacists are also highly trained to read prescriptions and assess the safety of medicines based on your specific conditions.

Created on September 1, 2006

Medication Safety Alerts

FDA Safety Alerts

Show Your Support!

ISMP needs your help to continue our life saving work