Confusion with “Use as directed” instructions

 

Sometimes, your doctor may write or send your prescription to the pharmacy with instructions to take the medicine “as directed.” In these cases, you must remember what the doctor has told you about how to take the medicine correctly. The label on the prescription container will not help you remember because the directions will simply say, “Use as directed.”

In 2016, nearly all the pharmacists who took part in a survey said they received prescriptions from doctors in the past year that did not include specific instructions for the patient. In fact, about half of the pharmacists said that approximately one out of every 20 prescriptions listed the instructions as “Use as directed.” The most common medicines prescribed using these vague instructions are listed in Table 1. Your pharmacist may contact your doctor to get more detailed instructions, but about half of the time, the directions on the prescription label will still simply say “Use as directed.”     Use as directed table

This has led to mistakes. Some patients never received any instructions about how to take the medicine. Others have forgotten the instructions they were given verbally. Occasionally, other information on the label, such as the strength of the medicine, has been misunderstood as the instructions. For instance, an elderly man was hospitalized after his son gave him the wrong dose of insulin. The specific dose was not listed on the prescription label. The insulin bottle was labeled with the name and strength of the insulin, “insulin aspart 100 units/mL.” But the amount of insulin that should have been given for each dose was not listed. The directions simply said to give the insulin three times a day before meals “as directed.” The man’s son thought the strength of the insulin listed on the label was his father’s dose. So, he gave his father 100 units of insulin. This is a very large dose that caused the man’s blood sugar to drop extremely low. A day prior to the error, the man had been discharged from a skilled nursing facility. Neither the man nor his son had been instructed regarding the insulin dose that should have been given before each meal.

“Use as directed” instructions have also led pharmacists to make mistakes. For example, we received three reports in which prescriptions for Visicol with directions to “Use as directed” were mistaken as prescriptions for Vicodin (hydrocodone, acetaminophen). Visicol was a bowel prep (this brand is no longer on the market) used to cleanse the colon prior to a colonoscopy. Up to 40 tablets were to be taken periodically with clear liquids for about 24 hours prior to the procedure. Vicodin is an opioid pain reliever. Only one or two tablets should be taken every 4 to 6 hours for pain. Both medicine names look and sound alike, so the pharmacists thought the prescriptions were for Vicodin. If the instructions had been included on the prescriptions, the pharmacists might have been able to distinguish between these two very different medicines. The number of tablets to be taken at one time are significantly different for each of these medicines. Two of the errors resulted in serious harm. These patients took more than a dozen Vicodin tablets over the course of a single day, leading to an overdose.

Here’s what you can do: Your doctor should provide you with specific verbal and written instruction on how to take your medicine. Specific instructions for use should also be included on prescriptions for all medicines. The only exception is for medicines that come from the pharmacy in dose packs because they already have the specific instructions listed on the package. Otherwise, if you receive a prescription medicine from the pharmacy with instructions to “Use as directed,” ask your pharmacist to call your doctor for the specific instructions. Do this even if you are confident that you know how to take your medicine. All medicines should be labeled with the specific directions for use. Ask your pharmacist to go over the instructions with you before you leave the pharmacy to be sure you understand how to take the medicine properly.

Created on September 29, 2017

Medication Safety Alerts

FDA Safety Alerts

Show Your Support!

ISMP needs your help to continue our life saving work