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Reporting a Medication Error

Don’t let the label on your new prescription be your only source of directions

84c42b9986b8cecdea81ed6abb66c108 MA 67-year-old man went to an emergency department because he was dizzy and had blurred vision. The doctor found he also had low blood pressure and a fast heart rate. The doctor admitted him to the hospital and prescribed medicines to raise his blood pressure and lower his heart rate.


Later that day, the man told a hospital pharmacist he had been taking Flomax (tamsulosin) 0.4 mg tablets three times a day for 2 weeks. The label on the prescription bottle said "Take daily after a meal." The man thought this meant to take the medicine after each of his three daily meals. But Flomax should only be taken once a day with a meal.

Some side effects of Flomax include dizziness, blurred vision, a rapid heartbeat, and low blood pressure. Once the doctor learned that the patient had been taking too much Flomax, he stopped all the new medicines he had prescribed and temporarily stopped the Flomax. The patient quickly got better.

Here's what you can do: To prevent this type of mistake, the pharmacy label would have been clearer if it had said, "Take one tablet by mouth once daily after eating breakfast." However, the pharmacy label should not be the only source of directions for taking a new medicine. The doctor who prescribes a new medicine should go over the directions with you, write them in your office record, and give you a copy.

Talk to your pharmacist every time you pick up a new prescription and the first few refills. Read the leaflet that comes with your medicine. When you first pick up your prescription, the pharmacist will review the directions with you. Repeat the instructions back to the pharmacist to be sure you understand them. Ask questions if the directions do not match what the doctor told you. If you have any unexpected side effects while taking the medicine, contact your doctor or pharmacist. When you pick up the first few refills, review the information with your pharmacist and discuss any other concerns you may have.

Article reviewed 8/11/2021

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