Medication Safety Articles

 

Our organization, the Institute for Safe Medication Practices (ISMP), often receives medication error reports that result from confusion with drug names that look or sound alike. One look-alike and sound-alike pair that often results in confusion is hydrALAZINE and hydrOXYzine.

Methotrexate is a medicine used to treat certain types of cancer. Doctors also prescribe methotrexate to treat other conditions such as severe rheumatoid arthritis and psoriasis (a skin condition). However, the dose and frequency of taking the medicine are different based on the condition being treated. For example, when used to treat cancer, methotrexate is often taken daily for 5 days or more at a higher dose. When used to treat rheumatoid arthritis or psoriasis, methotrexate is usually taken just once or twice a week at a lower dose. People often begin by taking a single 7.5 mg tablet once a week, or three 2.5 mg tablets per week, each taken 12 hours apart. The doctor may increase the weekly dose up to about 20 mg if needed. But if you take methotrexate every day by accident, you could be harmed. There are reports of this type of error probably because most people are more familiar with medicines taken every day rather than once a week. Some of these errors have even resulted in death.

Medicines all have one generic name and perhaps one or more brand names. The brand name is chosen by the drug company. The generic name is assigned by an official body, the United States Adopted Names (USAN) Council. You probably know, for example, that Advil and Motrin are brand names for the generic medicine ibuprofen. Knowing that Advil, Motrin, and ibuprofen are all the same medicine alerts you to an important risk—that taking these medicines together could add up to an overdose.

Patients sometimes ask to take home left over medicines that were partially used during their hospital stay (e.g., insulin pens, inhalers, eye drops, topical creams or ointments). An example of this involved a diabetic man who was taking the long-acting insulin Lantus (insulin glargine) and also received the short-acting insulin NovoLog (insulin aspart) during his hospitalization.

People who experience seizure activity (epilepsy) often take anti-seizure medicine to control the condition. However, sometimes additional medicine may be needed to control bouts of increased seizure activity (cluster seizures or breakthrough seizures). The Diastat AcuDial rectal administration system contains the medicine diazepam, rectal gel, to manage these breakthrough seizures. The product is available in a 10 mg rectal syringe designed to deliver a minimum dose of 5 mg, or a 20 mg rectal syringe designed to deliver a minimum dose of 12.5 mg. Both syringes allow for the dose to be increased by 2.5 mg up to a maximum of either 10 mg or 20 mg, respectively. (There is a 2.5 mg syringe for pediatrics.)

Giving a correctly filled prescription to the wrong customer is a common error in community pharmacies. If this has never happened to you, maybe you're surprised by this fact. But you are more likely to be among the millions of people who have gone home from the pharmacy only to find they have someone else's medicine inside the pharmacy bag.

Do you use an inhaler? If so, always replace its cap after use. The importance of replacing caps on inhalers was recently illustrated when a woman accidentally inhaled a small earring while using her asthma medicine. She got her uncapped inhaler from her purse. As she inhaled the medicine, she felt a painful scratch in her throat and started coughing blood. She was taken to the emergency department, where the earring was removed from her lung. If the inhaler's cap had been in place, the loose earring in her purse would not have gotten into the inhaler.

When people suddenly become ill or injured at home or in the community, they or their families or friends can call 911 for emergency help. But who can a patient or family member call upon once they arrive at the hospital if they feel their condition is seriously deteriorating and nobody is listening? Many hospitals today are offering patients and families an opportunity to summon an interdisciplinary care team to the bedside if they have unaddressed concerns. These teams are called Rapid Response Teams (RRTs).

Most people are familiar with throat lozenges. Typically, they are a small, medicated, round or oval shaped and dissolve slowly in your mouth. They are used to treat sore throats, coughs, and other throat irritations. Common lozenges include brand name products such as Chloraseptic, Delsym and Vicks (figure 1) and can be purchased over-the-counter (OTC).

Those who take Pradaxa (dabigatran) capsules may not know they should be swallowed whole. The capsules should never be broken, chewed, or opened to take the medicine. Studies have shown that the medicine absorbs too fast if the capsules are opened, chewed, or broken. This can cause serious bleeding.

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