Republished November 1, 2024
It was double trouble for a woman when she and her doctor both made errors that led to a 4-fold overdose of an antidepressant medication, Celexa (citalopram). The woman was starting this medicine 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 medicine together and realized what was causing the problem – a medication error.
Since this medicine was new for the patient, her doctor wanted to slowly introduce this medicine into her system. He verbally told the her to take half of the tablet for the first four days and then increase to a full tablet thereafter. Unfortunately, when the woman began taking the medicine 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 woman 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 ribavirin 200 mg capsules (used to treat chronic hepatitis) 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 woman who was given instructions to start her fertility injections, misheard the doctor, and incorrectly injected the medicine at the wrong time.
When receiving prescriptions for new medicines 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 instructions on how to take it to double check against the medicine bottle and label instructions you receive at the pharmacy. If your doctor prescribes by computer, he can print out a list of your medicines and their dosages. It is also important for your doctor to write down what each medicine is being used to treat.
It is also crucial when starting new medicines to review the drug information and speak with your pharmacist to become educated about the medicine, how to take it, and what side effects you may have. Too often consumers are overly confident that their healthcare 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 healthcare 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.
