The Food and Drug Administration (FDA) has been tracking medication errors since 1992. Since that time, more than 20,000 errors have been reported resulting in injuries and illnesses. These are voluntary reports, so the number of medication errors that actually occur is thought to be much higher. There is no “typical” medication error, and health professionals, patients, and their families are all involved.

A more recent study by the Institute of Medicine of the National Academies in 2006 reports medication errors are among the most common medical errors, harming at least 1.5 million people every year and the cost to treat these injuries are estimated to be $3.5 billion a year.

In the past, medication errors were attributed to poor penmanship or the use of unfamiliar abbreviations on the prescription. Now with new technology, other possible causes or errors have expanded to include labeling, packaging and product terminology.

The Institute for Safe Medication Practices (ISMP) identifies the following areas as potential causes of medication errors.

• Failed communication: handwriting and oral communications, especially over the telephone, drugs with similar names, missing or misplaced zeroes and decimal points, confusion between metric and apothecary systems of measure, use of nonstandard abbreviations, ambiguous or incomplete orders
• Poor drug distribution practices
• Complex or poorly designed technology
• Access to drugs by non-pharmacy personnel
• Workplace environmental problems that lead to increased job stress
• Dose miscalculations
• Lack of patient information
• Lack of patients’ understanding of their therapy

The National Council on Patient Information and Education (NCPIE) wants us to think about the three ‘Rs’.
1. Recognizing that all medicines have risks as well as benefits;
2. Respecting the power and value of medicines – properly used; and
3. Remembering medicine safety is also about personal responsibility – learning what you need to know to use your medicine safety and appropriately.
Patients must establish and maintain a strong partnership with their healthcare provider. Patients must be active partners in their medication care and physicians, nurses and pharmacists must know and act on patients’ medical care rights.

What Patients Can Do?
Read your prescription pill bottle
A doctor called in a prescription for the antibiotic Noroxin (norfloxacin) for a patient with a bladder infection. But the pharmacist thought the order was for Neurontin (gabapentin), a medication used to treat seizures. The good news is the patient read the medication leaflet stapled to his medication bag, noticed the drug he received is used to treat seizures, and then asked the pharmacist about it.

Find out what drug you’re taking and what it’s for.
Don’t just let a doctor write a prescription for you and take the medication. Ask questions. What’s the name of the drug and spell it for you. Also ask what it will treat.

Find out how to take the drug and make sure you understand the directions.
If your doctor tells you to take a medicine three times a day, find out when are you suppose to take it. In the morning? With food or on an empty stomach? Can you take it with orange juice?

Keep a list of all medications, including over the counter drugs and any supplements you may take.
Tell your doctor about all the drugs you are currently taking, even if they are over the counter medications. Sometimes mixing an over the counter drug with a prescribed drug can be deadly. If possible, get all your prescriptions filled at the same pharmacy so all of your records are in one place.

Here are some contacts to report medication errors:
The Food and Drug Administration
Accepts reports from consumers and health professionals about products regulated by the FDA, including drugs and medical devices, through MedWatch, the FDA’s safety information and adverse event reporting program.
1-800-332-1088
www.fda.gov/medwatch/how.htm

Institute for Safe Medication Practices
Accepts reports from consumers and health professionals related to medication. Publishes Safe Medicine, a consumer newsletter on medication errors.
1800 Byberry Rd., Suite 810
Huntingdon Valley,
PA 19006-3520
215-947-7797
www.ismp.org/Pages/Consumer.html

U.S. Pharmacopeia
MedMARX is an anonymous medication error reporting program used by hospitals.
www.medmarx.com
12601 Twinbrook Parkway Rockville, MD 20852
1-800-822-8772
www.usp.org