dahlia in my garden: Rio Fuego in Coleus leaves

Saturday, March 19, 2011

Medication Safety: Check & double-check to save your life (part one)

In my plant potting area, I have a number of spray bottles lined up in a row. Each one is for a different use in the garden: one kills certain pests, another is a weed-killer, one is a foliar fertilizer, one is a stain remover (how’d that get there?), another is insecticidal soap, and so on. The bottles are very similar in appearance and when you are focused on your gardening task it is easy to grab the wrong bottle... which could be catastrophic for the stunning new coleus seedling you potted if you spray it with weed-killer instead of foliar fertilizer!

It is no less dangerous with our medications. About three years ago, my HMO pharmacy made an error which could have severely harmed me or even ended my life. Please read on so that you will learn from my near tragic accident: 

I get most of my Rx refills by mail (via my HMO) in order to get a cheaper rate. After finishing one bottle of medication, I opened a new bottle for my morning medication regimen. I noticed the pills were different; I didn't think much of it because it has happened at least 3 times before, when my HMO has switched their formulary to a different drug manufacturer or had gone to a generic drug. I was pleased because the new pill was a little smaller and smoother, not like the normal pill which was larger and rough-edged.

I almost took the pill - I literally held it up to my mouth before stopping and decided that maybe I should have it checked out first. A little voice kept saying that something wasn’t right, and it kept pestering me until I decided that, though it was inconvenient, I would go to the pharmacy and ask about it. So I pulled out my "emergency medication pill case" in my purse, found what I knew was the correct pill, and put the odd pill back in the bottle. Then I headed off to the HMO pharmacy.

The pharmacist freaked when he saw the pills and everyone in the pharmacy was staring. He ordered me to go straight to the Emergency Room and it took several minutes to convince him I hadn't actually taken any of the medication.

He told me the medication was a very high dosage meant for controlling high blood pressure & heart problems. I asked what would have happened if I had taken it with my low blood pressure and other health problems. He said that I would have become critically ill & very well could have died - even if I had taken just one pill!

I was there in Pharmacy for almost two hours, watching the Pharmacist yell on the phone at different departments trying to report the situation and track down how the mistake had occurred. He came out to where I was sitting about every 20 minutes, apologizing a million times, promising to replace my medication and vowing to have the whole incident investigated.

Wow was I shocked! My husband nearly fell over when I told him. I had been so very, very close to taking the medication; it still gives me chills to think about it.


*Always check your medication BEFORE you leave the Pharmacy - even if you've taken it a million times - and report it if they look different to you.

*If you are picking up a brand new medication which you have never taken before, ask to speak the Pharmacist and OPEN the bottle in front him him/her. Make the pharmacist confirm that indeed, these new pills are the correct medication, the right dosage, and the instructions for taking them are printed correctly.

*If you get your meds by mail, DON’T take any pills that don't look right and have them checked out.

There is a website that can help you identify an unknown pill by its markings, color, and shape. It's a handy website which also offers info on side effects and drug interactions. Here's the link: The Pill Identifier   


The National Council on Patient Information and Education (NCPIE) has a website which is filled with vital information about medication safety and how you can protect yourself and your family. They really nailed it on the head with this advice:

What are the 5 “Rights” When it Comes to Safe Medicine Use?

Double-check each time. Medicines are approved in specific dosages to account for age and weight and to ensure the dose falls within the minimum amount needed to treat a condition and the maximum amount that might result in harm or unwanted side effects.

Each time you pull a medicine from your cabinet or drawer, double-check to make sure you have:

1. The right medicine

2. For the right person

3. In the right amount

4. At the right time

5. In the right way (swallow, chew, apply to the skin, etc.)

Here are more of the recommendations from NCPIE on how you can lower the risks and obtain the full benefits from your medicines.


•The brand and generic names.

•What should they look like.

•How to store them properly

•How and under what conditions you should stop using them.

•What to do if you miss a dose.

•What they are supposed to do and when to expect results.

•Side effects and interactions.

•Whether you need any tests or monitoring.

• Contact the doctor or pharmacist if new or unexpected symptoms or other problems appear.  

NEVER stop taking medicine the doctor has told you to finish just because symptoms disappear.

•Get expert advice before crushing or splitting tablets; some should only be swallowed whole.

•If your doctor writes a prescription out by hand, make sure you can read it. Also ask if he or she can indicate what the medicine is used for. For example, writing “take once daily for high blood pressure,” not just “take once daily.” 

A visit to the NCPIE website is a great idea; don’t miss all the menu links.

“Safety doesn't happen by accident. 
It isn’t expensive; it’s priceless.” 
-Author Unknown

I'm still shocked at what almost happened to me and how close I came to willingly taking a medication I knew didn’t look right. I am a far more cautious patient since this happened and I hope you will be too. 

Share this blog post with your family and friends; together, you and I could save another life.

Have you ever been given the wrong medication? Tell me what happened and what you did about it in the comments section below.

* Don't miss the rest of my MEDICATION SERIES *
click on these links:

1 comment:

  1. Thanks Shannon. I have had two relatives die because of medication issues.



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