Medication Safety Articles

 

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.

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.

Page 1 of 33

Medication Safety Alerts

FDA Safety Alerts

Show Your Support!

ISMP needs your help to continue our life saving work