What You Can Do to Prevent a Medication Error From Happening to You Or a Loved One

There are two very important things that you need to do prevent a medication error from happening to you or a loved one.

These are:

1) Partner with your doctor, pharmacist and nurse to optimize your healthcare and
2) Take responsibility for your own healthcare.

Partnering with your Doctor, Pharmacist and Nurse:

Your doctor is the expert on your medical care. There is no question that he or she makes the critical decisions regarding your healthcare. However, over the past few years there has been a growing initiative to encourage patients to take a more active role in their own healthcare. This is called "partnering" with your doctor.

"Partnering" with your doctor means that you will take an active role in understanding your medication therapy, monitoring your medications, recording your information and communicating it to your doctors.

In years past there has been the traditional "top down" medical system where the doctor simply gave the patient the information that they needed and expected the patient to follow it. We are now progressing towards a more cooperative system where the doctor and the patient enter into a dialog about the patient's care. Patients are encouraged to learn more about their medications including the names of the drug, why they are taking them and how they should take them. Patients are also learning what side effects to expect and what to do if they experience a side effect. They are also told what to do if they should miss a dose. Additionally patients are learning how to monitor the effects of the drugs, how to record that information and how to communicate this information to their doctor.

One of the most effective ways of preventing a medication error is to understand your own medication therapy. Partnering with your physician and becoming knowledgeable about your own medications is extremely important and would have prevented the following situation from happening.

Herb was taking on a blood thinner for a heart condition. He had been taking this medication for several years. Even though Herb's condition was well under control Herb still needed to take the blood thinner every day and to have his blood checked once a month.

Herb took 1 pill (5mg) of the blood thinner every day and had his blood checked every month. The blood test helped Herb's doctor make sure that Herb's blood was not getting too thin.

Herb took his medication as prescribed (1 pill every day) and went to the clinic have his blood checked. Herb waited for the nurse to call him back the next day with the test results and any new directions that he may need. This was the process that the doctor's office had set up and that Herb had followed successfully for the past 2 years.

As usual, the nurse called Herb the day after the blood test to give him his results. Instead of giving the results to Herb, the nurse gave the results to Edna, Herb's wife. The nurse also told Edna how Herb should continue to take the drug.

What the nurse told Edna was that Herb's "protime" was fine. It was 2.5. The nurse also told Edna that Herb should continue taking his warfarin "5" every day. The nurse assumed that Edna knew she meant for Herb to take one pill (5mg) every day as Herb had been taking all along.

What Edna understood the nurse to say was that Herb was supposed to take 5 pills every day. Herb did as he was told by his wife and took 5 pills every day for several days.

After a few days, Herb began to have nosebleeds that wouldn't stop, his gums bled after he brushed his teeth and there were some new bruises on his arms. Herb thought that it would be a good idea if he called his doctor. Herb was right.

Herb had been taking 5 of the 5mg tablets (or 25mg) of the blood thinner every day. This was five times the amount of blood thinner than he should have been taking. Herb was instructed by his doctor to go immediately to the Emergency Room. Herb was admitted to the hospital with near fatally thin blood.

Needless to say the complicated directions of this prescription and the misunderstanding between the nurse and Herb's wife nearly killed Herb.

If Herb had taken an active role in understanding his medicines this is what could have happened.

Herb thought that the information Edna gave him didn't sound right (5 pills??) After all, he had been taking warfarin for his atrial fibrillation for two years and had never taken that many pills at one time before. Sure, his doctor had adjusted the dose slightly every now and then but he had never been told to take 5 pills at once. Why would he be taking 5 pills if his protime was fine? Could Edna have gotten the message wrong from the nurse?

Having a "funny feeling" that the message was wrong Herb stopped and called the nurse for clarification of the directions before he took any of the medication. Telling the nurse that "It just didn't sound right" was perfectly fine. In fact the nurse thought that it was great that Herb had called. She was glad that Herb knew better to call her than to have a medication error.

Taking Responsibility for your own Healthcare

Taking responsibility for your own healthcare is not a simple thing. It is complicated and requires knowledge that we don't normally have. Additionally, when we are sick the last thing we want to worry about is what pill we take and why. We just do what our doctors tell us to do. In order to prevent a medication error, this has to change. You will need to become more knowledgeable and take responsibility for knowing what, why and how you take your medications.

You must take the responsibility for making sure that you understand what is being told to you. No one, not even your doctor can tell if you don't understand what he is telling you. Ask questions again and again if you need to. Definitely write it down. This is very important information that you are being given and your doctor expects that you have a clear understanding of what you are being told. This is what is meant by taking responsibility for your own healthcare. Your doctor, pharmacist and nurse are available to answer questions for you.

Remember, you must never leave the hospital, the doctor's office or the pharmacy without being absolutely sure of what you are being told. It is your responsibility to know and understand the important information that you are being given.

Mary Sue McAslan, Pharm.D.
America's Family Pharmacist
DrMarySue@americasfamilypharmacist.com
http://www.americasfamilypharmacist.com