Medication Safety Articles


A pharmacist recently heard from two people who mixed up their insulin pens and gave themselves the wrong insulin. First, a 67-year-old man with type 2 diabetes had been taking the long-acting insulin, Tresiba (insulin degludec), 70 units once daily. Because his blood sugar remained high, the man’s doctor also prescribed a rapid-acting insulin, Humalog (insulin lispro) to take with the first bite of dinner. Both of these insulins came in pens. One day, he accidentally took 70 units of the rapid-acting Humalog (which is a very large dose of rapid-acting insulin) instead of the long-acting Tresiba. He immediately realized the mistake and called the Poison Control Help line (1-800-222-1222). He had to check his blood sugar every 15 minutes for several hours and eat and drink sugary foods and beverages during this time to keep his blood sugar from dropping too low (hypoglycemia).

Confusion between the medicines Wakix (pitolisant) and Lasix (furosemide) was reported. Wakix is used to treat adults with narcolepsy (sleep disorder) for excessive daytime sleepiness. Lasix is a diuretic (or “water pill”) which increases the flow of urine to rid the body of excess fluid and salt. Using an online secure messaging system, a man was asking his doctor about a change in his dose of “Wakix” and whether he should get blood tests drawn. The man was also taking Lasix, and the dose had been changed several times over the years. The man had made several spelling errors when typing messages to his doctor. The doctor assumed the man had made a spelling error when typing “Wakix” and was instead talking about Lasix. Further questioning revealed the man actually was asking about Wakix.

Heading home after a hospital stay can be overwhelming. An important part of going home safely is understanding your medicines before you leave the hospital. The medicines you were taking before being hospitalized may have been changed or stopped, or new medicines may have been added during your hospital stay.

Calcium is the most abundant mineral in your body. It is needed to keep your bones and teeth healthy. Calcium also helps the heart, nerves, and muscles work well. To properly absorb and use calcium in your body, you need several other nutrients, including magnesium, phosphorous, and especially vitamin D and vitamin K. The best way to get calcium is through the food you eat. Calcium is found naturally in dairy products (e.g., milk, cheese) and is added to some drinks (e.g., orange juice, soy milk). But some people may need to take calcium supplements to get the recommended amount, especially older people as they start to lose bone with age.

The coronavirus (COVID-19) pandemic has overwhelmed the US and the world for many months, with no end in sight. As the fall season approaches, another health concern is on the horizon...the flu. The influenza (flu) virus commonly affects people during the fall and winter months, from about October through March. This year is expected to be extra challenging because of the COVID-19 pandemic. So, getting a flu vaccine is more important than ever this year to protect you, your family, and your community from the flu.

A mother picked up her child’s EpiPen Jr (epinephrine) autoinjector at a local pharmacy. Her child’s doctor had prescribed the autoinjector to use in an emergency caused by a severe peanut allergy. The mother was confused by the instructions printed on the pharmacy label: “Inject 0.3 mL intramuscularly one time as needed for anaphylaxis.” However, the strength of the EpiPen Jr autoinjector is displayed on the carton as 0.15 mg (Figure 1). The child’s mother was not sure why the pharmacy label said “0.3” while she was holding a carton that stated “0.15.”

In recent articles on—November/December 2019  and January/February 2020 —we described labeling problems with medical marijuana and how these can lead to errors. In this issue, we are going to focus on the growing concerns that some edible marijuana products may be appealing to children because they look like popular brands of candy found in stores.

A pharmacy almost dispensed the wrong birth control pills when filling a prescription. The near miss involved Tarina FE 1/20 EQ (norethindrone acetate, ethinyl estradiol, and ferrous fumarate) and Cyred EQ (desogestrel and ethinyl estradiol). Both birth control pills are made by Afaxys Pharma and come in similar-looking packages. The 28-day calendar packs come in pink and white pouches that look nearly identical. The cartons, which contain 3 calendar packs, also have the same pink and white color scheme.

Your prescription medicine may not be available at the pharmacy due to a drug shortage. This problem can happen for many reasons. Sometimes the company that makes the medicine does not have enough of one of the ingredients. Other times, the company has stopped making your medicine altogether.

Consumers can often spot a medication error by knowing what to expect. This includes knowing what medicine has been prescribed (for example, the name and dose), what the medicine looks like, and what side effects to expect. The following reported error and great catch shows the importance of knowing about the medicine you take.

Medication Safety Alerts

FDA Safety Alerts

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