Before leaving doctor’s office, expect medication information


It was double trouble for a patient when she and her doctor both made errors and it led to a 4-fold overdose of an antidepressant medication, CELEXA (citalopram Hydrobromide). The patient was starting this medication for the first time and after three days she began to experience severe anxiety, agitation, nausea, and severe fatigue. She called her doctor about her symptoms. The error was identified when they reviewed the medication together and realized what was causing the problem – a medication error.

Since the patient was starting Celexa for the first time, her doctor wanted to slowly introduce this medication into her system. He verbally told the patient to take ½ of the tablet for the first four days and then increase to a full tablet thereafter. Unfortunately, when the patient began this medication she did not recall these instructions and took a whole tablet for those first four days. To compound the problem, it was also discovered that the doctor accidentally wrote the prescription for 40 mg tablets and not 20 mg tablets as originally intended. Therefore, the patient was taking 40 mg of Celexa instead of the intended 10 mg starting dose, the reason for her symptoms.

Unfortunately, errors caused by misunderstanding prescription directions do occur frequently. For example, one patient who had a prescription for Rebetol (ribavirin) 200 mg capsules was instructed to take 600 mg in the morning and 800 mg in the evening. Despite the label instructions the patient thought she heard to take 800 mg daily. She went on to take 400 mg in the morning and 400 mg in the evening. Another example is a female patient who was given instructions to start her fertility injections, misheard the doctor, and incorrectly injected the medication at the wrong time.

When receiving prescriptions for new medications with specific directions, it’s critical that you leave the office with written instructions. Confirmation by your doctor that you understand those directions is also essential. Many people rely on trying to remember the directions only later to discover they misunderstood them. It is also best to have a written copy of the drug name, dose and administration instructions to double check against the medication and label instructions you receive at the pharmacy. If your doctor prescribes by computer, he can print out a list of your drugs and their dosages.

It is also crucial when starting new medications to review drug information and speak with your pharmacist to become educated about the medication, how to take it and what some of the downsides might be. Had the patient above done her homework it may have raised a red flag because starting doses are lower than 40 mg. Too often consumers are overly confident that their health care providers will not make mistakes. So much so that they do not take the time to confirm their prescriptions.

This scenario is a reminder that consumers are a critical component of their health care team and therefore must work together with their doctors to prevent medication errors. If you discover you physician wrote an erroneous prescription see this as a perfect opportunity to have a discussion with him/her about how the error occurred and ways they will work to prevent it from happening again. This conversation will show your commitment to protecting yourself and preventing future errors from happening again.

Created on January 26, 2011

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