Checking Pictures of Medications Saves Patients from Pharmacy Errors
Posted on Feb 04, 2012
Two patients in Florida narrowly avoided prescription drug error lawsuits by checking the medication they received against a photo of the drug—and finding that the two weren’t a match.
One patient was saved by the pharmacy’s method of labeling each drug with a description of the medication, including color, size, shape and numeric code printed on the pill.
“I checked the tablets and discovered that the bottle contained the wrong medicine,” the patient reported. “The color and shape were right, but the tablets were stamped with the wrong code.”
When the patient returned to the pharmacy to confirm the mistake, the pharmacist confirmed that he had been given the wrong pill; it was the correct medication, but the dosage was four times higher than his own prescription.
Another pharmacy customer reported an incident that took place over a decade ago, but could have cost her son his life.
The young man refilled his usual prescription for an anti-seizure medication and was taking it three times a day. He noticed a minor change in the pill, but didn’t think it was cause for alarm.
A few days later, he told his mother he was feeling unwell. When she looked up the medication in the image section of a drug reference book, his mother found that he had been taking Lasix, a powerful diuretic, instead of his anticonvulsant medication.
The man survived, but only because he was rushed to the emergency department and given an IV of potassium. “The doctor told me if my son had let this go another 24 hours, his heart would have stopped, and my son would have died,” the woman said.
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