PEOPLE’S PHARMACY : Medication Mistakes: Some Are Funny, Some Aren’t

The pharmacist, who asked to remain nameless, had a hard time stifling a snicker when he heard the patient’s complaint about the suppository that had been dispensed. The instructions on the label had been to insert the medicine every six hours. This unfortunate individual had not realized that it should have been unwrapped from the foil packet before insertion.

Such medication mistakes are far more common than most people realize. Sometimes people don’t understand ambiguous directions, resulting in situations such as the time a mother complained about the sticky, gooey mess the ear medicine made on her son’s pillow. She had poured a teaspoonful of antibiotic into his ear instead of giving it by mouth as intended.

Unfortunately, many mistakes are not nearly so humorous. One woman who had received a prescription for the acne medicine Accutane listened to the pharmacist explain in some detail that she would have to use extra contraceptive precautions because of the serious risk of birth defects. When he finished she looked puzzled. “Why are you telling me all this?” she asked. “My doctor said you can’t get pregnant on Accutane.”

This woman had misinterpreted her doctor’s admonition not to get pregnant as information that Accutane would prevent pregnancy. This could have led to a tragedy if the pharmacist had not caught the misunderstanding.

One major source of error in the pharmacy is the telephone. People often ask their doctors to call in a prescription so it will be ready when they get to the pharmacy. But many drugs sound similar over the telephone. If the connection isn’t clear or if the person on the other end of the line doesn’t speak distinctly, mistakes are possible.

If a pharmacist were to hear Klonopin instead of clonidine, a patient might receive an anticonvulsant instead of a high-blood pressure medicine. The antibiotics Cyclapen (cyclacillin) and Cyclopar (tetracycline) could readily be confused, a real problem for a patient with penicillin allergy.

Before taking any kind of medicine, make sure you understand exactly what the doctor had in mind. Then double check to confirm that what you get at the pharmacy is exactly what the doctor ordered. Everyone makes mistakes, but you shouldn’t have to pay for them with your life.