Medication Safety Articles

 

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.

Most people are aware of the need to keep medications out of children’s reach, but they don’t necessarily realize that similar rules apply when it comes to keeping pets safe. Pets can also get into medications that are not intended for them, which could cause harm. One case in point was recently reported.

A woman accidentally put ear wax removal drops (carbamide peroxide 6.5%) into her eye. This caused irritation and redness that persisted after rinsing her eye with water for 15 minutes. The bottle of ear wax removal drops (Figure 1) looks like a container used for eye drops. A warning that the drops are for the ears only is not on the front of the bottle (and carton) label. On the back of the carton, it says, “When using this product, do not get into eyes” in the Drug Facts table, but it does not stand out. This is mentioned on the side of the bottle, but the warning is buried in the middle of a paragraph in very small print.

Routine, recommended vaccines in the US currently offer some level of protection against 17 infectious diseases. One of these vaccines targets preteen boys and girls between 11 and 12 years of age—the human papillomavirus (HPV) vaccine. According to the 2017 Centers for Disease Control and Prevention (CDC) National Immunization Survey (NIS)-Teen, this vaccine is not widely used. Only 66% of boys and 67% of girls had received at least the first vaccine dose by age 15. Even fewer completed the full vaccine series of 2 to 3 doses—just 53% of girls and 48% of boys.

Just a handful of drugs are considered high-alert medications. These medications have been proven to be safe and effective, but serious harm can occur if they are not taken exactly as directed. This means that it is vitally important for patients to understand how errors happen with these medications, and the steps that are necessary to keep them safe while taking these medications.

Viruses that cause a cold or the flu are spread by droplets. This means you can get a cold or the flu from someone who is infected when they cough, sneeze, or talk. You can also get it by touching something that has viruses on it. But how do you know if you have a cold or the flu? And when should you seek medical care.

Drug abuse affects people from all walks of life. But when you hear about drug abuse, you tend to think of teens or young adults, not older adults. Unfortunately, drug abuse in older adults is also a serious problem. It occurs most often when the elderly misuse or abuse their own prescription medicines or when they intentionally take medicines prescribed for other people.

More than 30 million—nearly 1 in every 10—Americans have diabetes. To help manage their condition, many people with diabetes use a small, portable glucose meter to measure the amount of sugar (glucose) in their blood. After pricking the skin with a sharp lancet (small needle), one places a drop of blood on a test strip inserted in the glucose meter. The glucose meter then displays the blood sugar level on the screen. People with low or high blood sugar readings need to make quick treatment decisions. If the blood sugar reading is low, the person needs to eat or drink a sugary food or beverage, like candy, glucose tablets, or orange juice. This helps raise the amount of sugar in the blood to normal limits. If the reading is high, the person may need to take more insulin. The extra insulin helps lower the amount of sugar in the blood. If the blood sugar reading is normal, no additional food or medicine is needed. Unfortunately, mistakes have been made when making these treatment decisions due to the way the blood sugar results are displayed on some glucose meter screens.

Parents should be able to assume that the schools their children attend have a full-time nurse on site every day, but many do not. While the American Academy of Pediatrics (AAP)1 and the National Association of School Nurses (NASN)2 call for every school to have at least one full-time registered nurse on site all day, little has been done to make this a reality. Currently, only half of American schools have a full-time nurse on site every day.3,4 Thirty percent of schools have a part-time nurse, and nearly 20% do not have a school nurse at all.3,4 As schools contend with tight budgets, some nurses have been laid off, and many have been asked to cover multiple schools within the same school district. 

When an elderly man developed anemia, his physician advised the man’s daughter to give him 325 mg of ferrous sulfate (iron) tablets daily. Ferrous sulfate is taken to treat iron-deficiency anemia, a condition in which the body does not have enough healthy red blood cells due to low levels of iron in the body. The man’s daughter bought a bottle of “iron ferrous sulfate” from the pharmacy. The label said each tablet contained 65 mg (Figure 1, on page 1 of the PDF version), so she gave her father 5 tablets daily believing this would equal a 325 mg dose. However, each tablet actually contains 65 mg of elemental iron, which is equal to 325 mg of ferrous sulfate. Unfortunately, the label did not clearly state that each tablet contains 325 mg of ferrous sulfate. The information on the back of the label under Supplement Facts is also confusing. That part of the label says each tablet contains “Iron (as Ferrous Sulfate) 65 mg.” The elderly man developed severe constipation, a common side effect of iron even when given at the correct dose. He was soon hospitalized for other reasons. During his hospitalization, the mistake was recognized while reviewing the medicines the man had been taking at home.

Page 1 of 32

Medication Safety Alerts

FDA Safety Alerts

Show Your Support!

ISMP needs your help to continue our life saving work