Medication Safety Articles


The "memory enhancer" herb ginkgo biloba has been linked to bleeding problems. One of the components in this herb slows blood clotting. Consumers who take ginkgo with other medicines that prevent blood clots, such as Coumadin (warfarin) or aspirin, may increase their risk of bleeding.

While speaking with a consumer about a new prescription, a pharmacist noticed that a mistake had been made when interpreting the doctor's directions for taking the medicine. The patient's doctor had written a new prescription for Vicodin (hydrocodone and acetaminophen) to treat pain.

In 2007, the drug company that makes Omacor (omega-3-acid ethyl esters) changed the name of the medicine to Lovaza to prevent confusion with another medicine, Amicar (aminocaproic acid). Lovaza lowers triglycerides, and Amicar treats bleeding caused by problems with the blood clotting system.

A woman with asthma stopped by a pharmacy to talk with a pharmacist about her Pulmicort Flexhaler (budesonide inhalation powder). After trying many times to take her medicine, the woman said it felt like the inhaler was not working. The inhaler keeps track of how many doses are left (see photo). But the number on the dose counter did not seem to be moving.

In any given week, four out of five adults will take a prescription or over-the-counter (OTC) medicine. The more information you have about your medicine, the better able you will be to use it properly. But when it comes to prescription medicine, a 2006 study at the University of California in Los Angeles showed that patients left the doctor's office without at least one of these key pieces of information about their new medicine:

If you are hospitalized, nurses will typically give you the medicine your doctor has prescribed. But if the medicine the nurse brings to you doesn’t seem right, it might be that an error has happened. You may be hesitant to speak up about the potential problem. You may believe your doctor and nurse know more about medicine than you do. But in some cases, your instincts may be right, as in the example that follows.

A pregnant woman was given a prescription for "PNV" tablets. The doctor used this abbreviation for "prenatal vitamins." The pharmacist mistakenly thought that PNV stood for "penicillin VK," an antibiotic. He filled the woman's prescription with penicillin tablets in error.

When a middle-aged man arrived at a pharmacy to pick up a refill for lactulose (a common laxative), he was told that he needed a new prescription from his doctor. There were no refills left on his previous prescription. The pharmacist suggested that the man could use KARO corn syrup as a substitute for lactulose until he visited his doctor for his next check-up.

A mother picked up a refill for her child for Strattera (atomoxetine), a drug used to treat attention-deficit/hyperactivity disorder. The capsules were a different color than with previous refills. Even though the prescription bottle said Strattera 60 mg, the mother called the pharmacy to check.

A child's mother brought a prescription for Reglan (metoclopramide) syrup to the pharmacy. When the prescription was ready, the pharmacist showed the mother how to measure the medicine dose with an oral syringe. The mother then realized that she had not been measuring her child's dose correctly for another medicine, Zantac (ranitidine) syrup. This prescription had been filled at a different pharmacy.

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