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Reporting a Medication Error

Please, please, open the bag!

10dc0c0d83cf5ec5b13a99f94232defb MOne 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.

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