Medication Safety Articles

 

Why is it important for pharmacy staff to ask for your birthdate, address, or other identification every time you pick up a filled prescription? It is a way to help make sure that medicines are handed to the right person.

After nearly 2 weeks in a neonatal intensive care unit, a newborn baby was discharged to home with a prescription for liquid phenobarbital (20 mg per 5 mL) twice a day to prevent seizures. Before leaving the hospital, the baby’s doctor reviewed the prescription with the parents. He made sure the parents knew the baby’s dose (6.5 mg) and how much of the liquid medicine to give the baby for each dose (1.6 mL).

Today, 33 states plus the District of Columbia (Washington, DC) have legalized medical marijuana (and 11 states plus DC have legalized recreational use of marijuana). Medical marijuana is different than the street product. With medical marijuana, growers must confirm the products’ contents, so this information can be passed on to dispensaries and patients. However, each state has its own regulations for medical marijuana. This has resulted in a wide variety of medical marijuana products and safety concerns, particularly with the labeling of these products.

The 2019-2020 flu season is upon us. On average, 1 in 10 Americans get sick with the flu each year. Children are twice as likely to develop the flu than older adults, and children younger than 5 years are especially susceptible to serious flu-related complications. People 65 years and older, pregnant women, and people of any age with a chronic condition like asthma or diabetes are also at high risk of developing serious complications from the flu. 

One of the most frequent errors in the pharmacy is giving a correctly filled prescription medicine to the wrong customer. Recently, we received another report of this type of error. A parent of a 16-year-old teen picked up what was supposed to be an antibiotic to treat his acne, minocycline. The next month, when looking at the prescription label to call in a refill of the medicine, the teen’s mother realized the prescription medicine was for a different person, and the medicine dispensed was not minocycline. Instead, Xarelto (rivaroxaban), a medicine used to prevent blood clots after surgery or in people at risk of having a stroke, was listed on the label. Fortunately, the teen was not injured. However, the risk of bleeding from taking Xarelto in error for a month is certainly significant.

Here’s what you can do: An effective way to detect this error right away is to open the bag of medicine when picking up filled prescriptions at the pharmacy. Make sure the correct person’s name and the expected medicine, dose, and directions are listed on each bottle. Always provide your full name (or the name of the person the prescription is for) and date of birth when picking up medicines. Ask to speak to the pharmacist to review how to take the medicine. This can also help catch errors if the medicine, dose, or directions are different than you expect, or if the reason for taking the medicine does not match your needs. If the medicine is not what you expected, don’t be afraid to tell the pharmacist you do not think it is right.

The oral syringes that come with risperidone oral solutions are uniquely labeled and may cause confusion. Risperidone is a medicine used to treat certain mood disorders. Unlike other oral syringes, risperidone oral syringes have a barrel (the part that holds the medicine) that does not have any lines or numbers (markings). Instead, the markings appear on the plunger (Figure 1). To measure a dose, the plunger must be pulled back until the dose marking aligns with the flange (winged end) of the barrel. Even though these syringes are different than other oral syringes, the instructions do not provide detailed, clearly illustrated information on how to read the markings when measuring a dose. We recently learned about a man who may have taken too much risperidone due to confusion with the dose markings.

With birth control pills (e.g., Tri-Estarylla, Tri-Linyah), confusion is possible between the week 1 tablets that contain norgestimate and ethinyl estradiol and the week 4 tablets that do not contain any medicine. Different brands of these birth control pills have the same medicine and dose in the active tablets, but the tablet colors vary (Table 1).

A medicine commonly used to treat depression, sertraline (Zoloft), is available as a tablet or a concentrated oral liquid. The oral liquid form is very potent and must first be diluted in a specific beverage to make it easier to swallow. However, many healthcare providers and consumers are unfamiliar with the need to dilute this medicine before use.

Most prescriptions can be transferred between pharmacies in the US. You may need to do this for several reasons:

· You are moving to a new location

· You are looking for a more convenient pharmacy location

· You recently made changes to your health insurance that require you to use a different preferred pharmacy

· You need to obtain a temporary supply of your medicines because you did not bring enough with you while traveling

But take care, as errors have happened when transferring prescriptions between pharmacies.

Pharmacists from the Maryland Poison Center recently published several cases of what they refer to as “pill dumping.” An article in the American Journal of Health-System Pharmacy1 describes the term “pill dumping” for when patients use a spare medication vial to hold multiple medications taken from different labeled prescription vials.

Page 1 of 33

Medication Safety Alerts

FDA Safety Alerts

Show Your Support!

ISMP needs your help to continue our life saving work