Recently, a friend’s 4 year old child was prescribed medicine by a doctor for a cough and had it filled at a local pharmacy. Fortunately, my friend double-checked the medication (he learned it was for depression and insomnia) and dose (adult size doses) and then called the doctor’s office to confirm that these were the proper prescriptions.
The doctor’s office was aghast, expressing fear that these incorrect medications may have been given to the child.
Any fan of “It’s A Wonderful Life” will recall the scene when the young George Bailey saves pharmacist Mr. Gower from dispensing a dangerous dose of poison. I was reminded by my friend’s misadventure that these mistakes can still happen today. Fortunately a possible fatal consequence was averted.
According to the U.S. Food and Drug Administration, medication errors cause at least 1 death/day and injure approximately 1.3 million people annually in the United States.
Medication mishaps can occur anywhere in the distribution system: Prescribing, Repackaging, Dispensing, Administering or Monitoring.
Prescription medication use is wide spread, complex and increasingly risky. Clinicians have access to a medicine cabinet of more than 10,000 prescription medications and nearly one-third of adults in the United States take 5 or more medications.
Taking more medications than clinically indicated is likely the strongest risk factor for adverse drug events (ADE’s). Elderly patients, who take more medications and are more vulnerable to specific medication adverse affects. Also, pediatric patients, particularly when hospitalized, are at risk since many medications for children must be dosed according to their weight.
To prevent adverse drug events, it is important to understand the pathway between a clinician’s decision to prescribe a medication and the patient actually receiving the medication.
There are 4 Steps:
- Ordering: The clinician must select the appropriate medication and dose and the frequency at which it is to be administered.
- Transcribing: In a paper-based system, an intermediary (a clerk in a hospital setting or a pharmacist or pharmacy technician in the out-patient setting) must read and interpret the prescription correctly.
- Dispensing: The pharmacist must check for drug-drug interactions and allergies then release the appropriate quantity of the medication in the correct form.
- Administration: The correct medication must be supplied to the correct patient at the correct time. In the hospital, this is generally a nurse’s responsibility, but at home this is the responsibility of patients or caregivers.
Of these steps, the patient may have control only over one: Administration.
Below are the 5 “Rights” when administering medications:
- Administering the right medication
- in the right dose
- at the right time
- by the right route
- to the right patient.
My friend, after picking up the medications from his local pharmacy Googled the name of each medication. When he had questions, he called the doctor’s office. Had this diligent parent not taken those steps, a tragedy may have ensued. His close call is a reminder to all of us that we must be ever vigilant when taking prescribed medications.