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Medication Mistakes Could Be Deadly

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When an airplane crashes, the public demands to know what went wrong. They also want the problem to be corrected so it won't happen again.

When it comes to medicine, however, there are rarely investigations. It is relatively unusual for someone to be held accountable for a medication mistake, and there has been little progress on putting fail-safe systems in place to prevent the estimated 60 million medication dispensing errors each year.

We heard from a woman whose mother died because she was mistakenly dispensed the hormone estradiol instead of her prescribed blood thinner, Coumadin (warfarin). The writer wondered if others had experienced similar problems.

We have indeed heard from a number of people concerned about pharmacy errors. One woman on a regular anti-anxiety medicine for panic attacks picked up a refill from the pharmacy without realizing that she had been given a much lower dose. After taking it, she began to sweat and shake and felt terrified. She didn't realize what was happening, but she was experiencing sudden withdrawal symptoms because of the lower dose.

This woman tried to drive to her daughter's home nearby but was pulled over by the police. When her daughter, an EMT, tried to come to her aid, she was arrested. Fortunately, no one was physically injured from this pharmacy mistake. Both she and her daughter had records and court fines as a consequence, however, and emotional scars linger.

Another reader reports: "Just this past Saturday, my husband had a prescription filled for nitroglycerin SA 6.5 mg. He has been taking this drug for some years following a heart attack.

"When he started to take the medicine, he noticed the color was different. Upon checking the pharmacy label stating 6.5 mg., the manufacturer's label underneath stated 9 mg. We returned to the pharmacy to have them checked and, sure enough, the dose was wrong."

A pharmacist chimed in: "I am a pharmacist for a large retail chain. I am always deeply saddened to learn of a death that was preventable. Pharmacists make mistakes, I admit, but what about patient responsibility? If the patient noticed the tablets looked different, did she contact the pharmacy and ask questions?"

While many patients may have no difficulty asking questions at the pharmacy, questioning the physician is a different matter. We heard from one reader whose experience is not unusual: "I am president of a publishing company and have no problem being assertive with authors, colleagues and vendors. When I saw my doctor recently I was pleased to note that she washed her hands carefully before starting the exam. But I noticed that she did not bother to clean the stethoscope she wore around her neck.

"I asked my doctor how often she cleaned her stethoscope and she admitted that she probably only did it about once or twice a week. She commenced to listen to my heart and lungs with that same stethoscope and I didn't have the nerve to ask her to clean it. I can only guess how many germs were on it. Doubtless some were passed to me from previous patients and my germs were likely passed on to dozens of other patients.
"I didn't get sick but I was surprised at my inability to speak up and ask her to clean the bell of her stethoscope. I wonder if other people have as much difficulty being assertive with a doctor as I did."

Even though it can be difficult to stand up to health professionals, it often makes a big difference. One woman told us, "My sister and I were very concerned about my 73-year-old aunt and the tremendous number of medications she was on. She was in a terrible nursing home and was continually strapped in a wheelchair. She was always agitated and often spoke to people who had been dead quite awhile.

"The doctors said her hallucinations were caused by a stroke and dementia. Her family was in complete denial. My sister used your Drug Safety Questionnaire and we found some serious problems with her medicines.

"We moved her to a different facility. Two weeks after the medicines were stopped or the doses were lowered, she has become herself again. Thanks for helping us get our wonderful aunt back!"

Whether you are advocating for a family member or for your own health care, it is essential to prepare for a doctor's visit or hospital stay in advance. Take a prioritized list of your top health concerns. If possible, bring an assertive friend or family member to be your advocate. If you get too frightened to speak up for yourself, this person can ask questions and talk for you.

We have several Top 10 lists of questions and tips to avoid diagnostic mistakes, hospital errors, adverse drug reactions and interactions in our book Top Screwups Doctors Make and How to Avoid Them. You will also find our Drug Safety Questionnaire that you can copy and give to the doctor, nurse and pharmacist to fill out. That way you can compare their answers to make sure you are getting the full picture. Our book is available in libraries and bookstores. You can purchase an autographed copy online at www.peoplespharmacy.com.

If you would like a FREE copy of just our Drug Safety Questionnaire and Medical History form you can download it by going to this link. We encourage you to make photocopies of it and have all your health professionals fill it out. While you are at it, why not encourage a friend to sign up for our free newsletter. That way she could also get access to the free Drug Safety Questionnaire and save 15% on any purchase in The People's Pharmacy store.


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5 Comments

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I don't understand why the mother and daughter were arrested in the medical error you cited above with Warfarin and Estridiol. Did they get combative in some way. maybe you could clarify.

First- Where is the"Medical History" second sheet?

Second- Trying to get a physician to fill out the "Drug Safety Questionaire" is a hopeless project. Daily I take 5 meds.- One for cholesteral, 2 for high blood pressure, and 3 to regulate my heart rate, plus 2 baby aspirins and a multi vitamin. I have a prescription for Xanax which i use only as needed to sleep.

2 meds plus the aspirin are prescribed by a cardiologist, the others by my family doctor. Neither of these doctors would take the time to fill out these forms, 15 minutes is about all the alloted time for my visits. They would laugh me out of their offices if I requested them to do this. My family physician gets enraged at the mention of The People's Pharmacy" and the cardiologist brushes off any questions.

Most of the "Drug Safety Questionaire" information is available with the filled prescriptions I get through mail order from Merck or Caremark and if one takes the time to read it carefully it is clear.

THE BIG QUESTION IS HOW SAFE ARE THE PRESCRIPTIONS IN THE AMOUNT THEY ARE PRESCRIBED AND WHAT INTERACTIONS ARE THERE. I WAS PRESCRIBED 40 MG. SIMVASTIN AND 10 MG. NORVASC UNTIL FDA PUBLISHED A WARNING ABOUT THE INTERACTION OF THESE 2 MEDS. I WAS HAVING ALARMING CREATININE INCREASED LEVELS AND NOBODY, INCLUDING A KIDNEY SPECIALIST AND A UROLOGIST, LOOKED AT THE PRESCRIPTIONS I WAS TAKING. NOW TAKING 10 MG SIMVASTIN AND 5 MG NORVASC ON MY OWN. I FEEL GOOD AND WONDER IF THE DRUGS COULD BE FURTHER REDUCED.

DOCTORS ARE NOT GODS AND ARE NOT ALWAYS RIGHT.

THANK YOU PEOPLE'S PHARMACY AND THANK YOU FDA FOR PUBLISHING WARNINGS.

Here is the second sheet: https://store.peoplespharmacy.com/catalog/product/gallery/id/559/image/424/

I too would like to hear the answer to LG's query.

You might want to look at MediGuard.org. But I think you could also ask for a consultation with a pharmacist and keep all your prescriptions at the same pharmacy. And of course keep reading the People's Pharmacy.

While visiting my son in Atlanta, I had a stroke and when I was in the ER I told them I knew I had a stroke (could not lift my right arm and could not control movement in my left arm) but because I was lucid they did not believe me and blood work and a scan were all negative and only after an MRI was done that showed two infarcts in the cerebella did they acknowledge the stroke.

By then 6 or 7 hours elapsed so the clot buster treatment could not be done. Then I was transferred to a stroke center. Then I was told a scan often does not show a stroke. Do why did they not do the MRI first? Is protocol so rigid that first hand information is ignored?

I think because I am 80 they thought I was a senile old woman. My son did not have a thorough history on me so they waited to talk to my 3 daughters who came a day later. Please give me your thoughts on this.

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