Medication Safety Articles


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.

The name of a unique inhaler device included in five different brand name medicines has led to multiple mix-ups, not only by consumers but by doctors, pharmacists, and nurses as well. In 2013, the global drug company, GlaxoSmithKline, introduced Ellipta, a new type of inhaler device. It is circular in shape, about the size of a hockey puck, and can combine several different medicines together. The company has packaged combinations of one, two, or three of the medicines listed below using this unique inhaler device:

Boric acid suppositories are sometimes used to treat chronic vaginal infections when traditional treatments have failed. Vaginal infections are typically treated with antibiotics, such as metronidazole. For some women, the infection comes back right away. When this happens, some doctors will recommend trying boric acid suppositories.

Certain medicines can cause damage to the vocal cords. The vocal cords are two bands of elastic muscle tissue that sit side-by-side in the voice box at the back of the throat. When you are silent, the vocal cords remain open so you can inhale air into your lungs. When you speak or make other sounds, the vocal cords close and vibrate as you exhale air from your lungs.

Caution is advised regarding labeling and packaging of acetaminophen liquid products now on store shelves at several leading chain pharmacies.

Medicines are a leading cause of accidental poisonings in young children. When we think about this, older babies and toddlers who can scoot, crawl, walk, and/or climb come to mind. Older babies and toddlers are curious and explore their world by “mouthing” the items they find. If they see something that looks interesting, they often reach for it or climb to it. Therefore, it is important to keep medicines and other potentially toxic products up and away and out of the sight and reach of children.

Insulin is required for people with type 1 diabetes and sometimes for people with type 2 diabetes. Many people who take insulin use an insulin pen. The correct insulin dose is dialed on the pen, the needle is inserted under the skin, and the insulin is injected though the needle once the button is pushed. The needle is disposable. So, after each injection, the used needle should be removed. A new disposable needle should be screwed onto the pen before each injection.

Some medicines, including many prescribed for children, come in a powder form. Water must be added to the powder so the medicine can be easily measured and taken. The ratio of water to powder must be precise, so that the prescribed amount of the final liquid mixture provides the correct dose of medicine per milliliter (mL). It is best for the pharmacist to add water right before the medicine is picked up. Once mixed, the medicine often needs to be refrigerated to stay potent. But if the pharmacist forgets to add the water, or if the wrong amount of water is added at home, a serious dosing error can occur.

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