Medication Mistakes

Some 700 errors in writing and fulfilling drug prescriptions are reported yearly to the U.S. Pharmacopeia, the scientific organization that establishes drug standards. This is a very conservative estimate due to the fact that there are no requirements for reporting mix-ups, and no accurate records are kept.

The risk of error is growing every day with the addition of new medications, some with dangerously similar names. It is estimated that 2 million Americans are hospitalized annually from drug side effects.

"Pharmacists have the tremendous pressure of volume and numbers," says Dr. Raymond Woosley of Georgetown University Medical Center. "So they have to get them out. That means they take less time to look at the prescription. They're less likely to double-check or triple-check to make sure that's the right drug the physician wanted."

An even more dangerous, less obvious problem occurs when pharmacists, following directions from managed care companies, switch medications intentionally. These "preferred" drugs are usually available to managed care companies at a discount. By switching prescribed medications with those found on this list, pharmacists are often substituting one chemical compound for another that produces completely different side effects.

"During that period of time," explains Woosley, "a diabetic can develop a kidney infection. A patient with heart disease can develop a heart attack. A patient on a beta-blocker could develop a stroke."

Use the following recommendations from the National Coordinating Council for Medication Error Reporting and Prevention, to make sure your physician writes prescriptions in the most understandable format possible.

• All prescriptions must be legible.
• If you cannot read the prescription your physician hands you, chances are the nurse or pharmacist will have trouble deciphering it also. Ask your physician to rewrite it clearly.
• Prescriptions should include a brief notation of the purpose of the drug.
• Prescriptions should include the age, and when appropriate, the weight of the person for whom the drug is prescribed.
• A zero should always be placed before a decimal if the prescription is for an amount less than 1. A zero should never be placed after a decimal.
• Prescribers should not use vague instructions such as "Take as directed" or "Use as needed". Directions should include clear, specific recommendations on how much medication to take and how often to take it.
• Prescribers should avoid using abbreviations. Many widely used abbreviations come from Latin derivatives and can easily be misunderstood.