Drug Topics - July 21, 2008 - (Page 3) 3 REDUCING YOUR RISK Ken Baker, B.S. Pharm., J.D. The patient's role in preventing drug errors T he pharmacy technician called the names of both the elderly husband and his equally elderly wife. The gentleman stepped forward and was given two prescription bags. One bag had stapled to it two receipts labeled with the wife’s name. The other bag, with the husband’s name on it, had one receipt attached. All three of the prescriptions were refills, so the technician merely asked, “Do you have any questions for the pharmacist? “No,” the husband said. The bag with the wife’s two receipts stapled to it contained only one prescription bottle. That one prescription was the husband’s prescription, correctly filled, but placed in the wrong bag. The husband’s bag contained both of the wife’s correctly filled prescriptions. For almost a full month the husband took both of the wife’s prescriptions and the wife took the husband’s one prescription. After the wife was hospitalized, we asked the husband why he had taken the two prescriptions that were clearly labeled with his wife’s name. “I took what the pharmacist gave me. I did not look at the name on the label. They were in my bag, they had to be mine,” the husband said. The first reaction was to accept the couple’s actions as signs of dementia. While the husband was an older gentleman, he seemed intelligent and fully in charge of his facilities. It seemed to never cross his mind that the pharmacy could have made an error. Whenever a patient takes a medication that is clearly wrong—a different color, shape, or size—the pharmacist invariably asks the question, “Why did they take it? Isn’t the patient also at fault?” The best answer, however, is to prevent injury before the patient takes any of the erroneously filled prescription. As part of a continuous quality improvement (CQI) program, technicians and pharmacists are trained to look for mistakes and if there is any question, it must be resolved before proceeding further. There is one other important player—the patient. You can ask the patient to: 1. Carefully examine every prescription and refill including reading the label and accompanying information. 2. If the appearance of your medicine changes, we will tell you. If we did not, do not take the medicine until you talk to your pharmacist. 3. If you have a question about your medicine or suspect there could be an error involved, ask to speak to a pharmacist. If the pharmacist is busy, ask the pharmacy to call you. Do not take the questioned medication until your inquiry has been answered. 4. Keep a list of all medications you are taking, including over-the-counter products, vitamins, and herbals. Carry the list with you and show it to your physician and pharmacy each time. Your pharmacist will be glad to provide you with a list of all of your prescriptions filled at his pharmacy. 5. Choose one pharmacy for all of your prescriptions. Your pharmacist can best serve you if the pharmacy has a complete list of all medications you are taking. 6. Your pharmacist may ask you questions to find out what you already know about your medicines. If you are not sure, please ask your pharmacist. 7. For each medication you should know what side effects are most likely and what to do if you have any of them. 8. For each medication, know how you are to take it—how often, when, and for how long. 9. Each time you visit your pharmacist or physician, write down any questions you may have and make sure your questions are answered. 10. Your physician and your pharmacist have years of education and training – use that knowledge. Ask questions. 11. No one knows your health as well as you. Educate yourself when possible regarding your health and medications. In addition to your pharmacist and physician, the Internet and the public library are sources of information. 12. Get to know your pharmacist and physician. Each can be valuable in making you well and keeping you healthy. A part of the pharmacist's job today is to assist patients in managing their medication risks. This article does not constitute legal or consultative risk management advice. You should not rely on the information here or in any similar article for a plan of quality or for legal matters. Consult a risk management consultant or an attorney. THE AUTHOR practices law as an attorney, of counsel, with the Arizona law firm of Renaud Cook Drury Mesaros, PA. He also consults in the areas of pharmacy error reduction and risk management. For questions or citation and footnotes, you can reach him at ken@kenbakerconsulting.com.
Table of Contents Feed for the Digital Edition of Drug Topics - July 21, 2008 Drug Topics - July 21, 2008 Contents The Patient's Role in Preventing Drug Errors Wireless Connectivity Making Smart Pumps Wiser Hospira Markets Smart Pump with a New Interface Drug Topics - July 21, 2008 Drug Topics - July 21, 2008 - Contents (Page 1) Drug Topics - July 21, 2008 - Contents (Page 2) Drug Topics - July 21, 2008 - The Patient's Role in Preventing Drug Errors (Page 3) Drug Topics - July 21, 2008 - Wireless Connectivity Making Smart Pumps Wiser (Page 4) Drug Topics - July 21, 2008 - Wireless Connectivity Making Smart Pumps Wiser (Page 5) Drug Topics - July 21, 2008 - Hospira Markets Smart Pump with a New Interface (Page 6)
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