Medication Safety Articles

 

Caregivers of small children who are either hospitalized or visiting someone in the hospital should be aware of an unsuspecting source of choking. The small object is called a disinfection cap and is commonly used in the healthcare setting as a barrier on an intravenous port. The small cap has a foam sponge inside saturated with alcohol to help prevent infection. However, these brightly colored caps may be attractive to young children and could be a potential choking hazard.

Almost two-thirds of adults in the US own a smart phone and/or tablet. These high-tech devices have led to an abundance of apps that hold promise to engage people in managing their health care.

CVS brand of Arthritis Pain Relief extended-release tablets come in geltabs containing 650 mg of acetaminophen. A single dose is typically 650 mg, or one geltab. Several people who live in a retirement community reported that they found the markings on the geltabs that state “350” to be confusing (image below). Several thought the “350” designation on the tablet meant its strength—350 mg. They thought they had to take two of the geltabs as a single dose, but again were confused because two of the geltabs would equal 700 mg, not the 650 mg dose they thought they were supposed to take.

Have you ever thought about where medicines are kept in your home through the eyes of your child? Medicines left on counters, nightstands, in purses and bags, or on the ground are easily within reach of a young child. What's more, many medicines are brightly colored and look like candy, making them appetizing to children.

Brintellix and Brilinta mix-ups. An elderly woman required hospitalization when the pharmacy confused Brintellix and Brilinta and gave her the wrong medicine. Brintellix (vortioxetine) is a medicine used to treat depression. Brilinta (ticagrelor) is a medicine that helps to prevent clots in patients with certain heart diseases. The woman was given a prescription for Brilinta 90 mg to take twice a day. But the pharmacy staff misread the medicine label on the bottle that was selected from the shelf and filled the prescription with Brintellix 10 mg. The medicine bottles for Brilinta and Brintellix were on the same shelf, side-by-side, and the wrong bottle was picked up.

Oral chemotherapy is cancer medicine that is taken by mouth. These medicines come as tablets, capsules, or liquids that can be swallowed. As a result, oral chemotherapy can be taken at home. For people with cancer, taking a medicine by mouth is easier than intravenous (IV) chemotherapy given through a vein because they don't have to go to the hospital or clinic to have the medicine administered. However, even though these medicines can be taken by mouth, they are not necessarily safer than IV chemotherapy. In fact, chemotherapy pills can be just as strong as the chemotherapy given through a vein by injections and infusions. Mistakes with oral chemotherapy medicine can lead to serious side effects and even death.

Many people rely on prescription and/or over-the-counter (OTC) medicines to treat an array of conditions. When traveling, either for business or leisure, that doesn’t change. So, if you will be traveling outside your home country, there is something important you need to know about medicines. The country you are traveling to may have the same brand name medicine available but it may actually contain a different ingredient that is used to treat a different condition.

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.

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