Medicine Mix-Up May Happen More Than You Think

Consumers may want to check the medicine labels

Like any toddler, Jordan Woodson doesn't always like taking medicines for his ear infections.  The last time he was sick, his refusal to take his antibiotics saved him from getting an overdose, his parents say.

And now, they want to warn other parents about what happened.

Jordan's mom, Tiffani, remembers mixing what she thought was an unusually large amount of antibiotic into the oatmeal she hoped Jordan would eat.

"I'm like, 'This is a lot of food and a lot of medicine.'  It just didn't really seem right, " she recalled. But she assumed it was because Jordan had grown and probably needed more medicine than before, she said.

In any case, Jordan kept saying no, and Tiffani finally decided to go to the pharmacy and get flavoring added to the prescription.  She hoped that would do the trick. When she arrived she learned something that made her sick.

"That's when they told me they tried to call my house because they had found an error, " she said.

"I'm like, 'So that was wrong?' And they said, 'Yeah, that was wrong, it was like three times the dose.'"

If Jordan hadn't refused, he would have gotten an overdose twice a day for 10 days.

The Woodsons are not alone. It's true that studies show that retail pharmacies get prescriptions right 98.3 percent of the time. That doesn't sound bad, according to Bruce Lambert, who studies medication errors at the University of Illinois at Chicago.

"(But) when you consider that about 4 billion prescriptions are dispensed every year in the United States, you realize that's 68 million errors a year. So it doesn't seem so good," he said.

It's important to note that the vast majority of medication errors don't do significant harm to patients, only causing mild discomfort.   But at the severe end of the spectrum, an error can kill a patient, Lambert said.

Drug companies continue to bring new medications to the market, and Americans are becoming accustomed to taking more than one prescription. And with health care costs rising, they often shop at more than one pharmacy, hoping to get a better deal.

"Even as pharmacists try to get better and safer at doing this, they work in an environment which keeps making their job harder," Lambert said.

And that leaves the patient as the last line of defense against a prescription error.

Lambert's first suggestion is not to take the drug at all if you don't need to.

If a doctor suggests a drug, he suggests asking, "Is there a non drug treatment for this? Can we wait a while to see if this resolves on its own without taking any medicine?

Is there an over-the-counter medication I can take?"

But if a prescription is your only option, then start by keeping a copy of it, so you can compare it with the label.

Wrong label information is the most common prescription error.

It takes just a few moments to also make sure that the strength and dosage are what the doctor prescribed.

It's something you may want to do even if you're getting a refill. Studies have found that errors can be made then, as well.

Other problems include look-alike or sound-alike names.

Oxycontin or oxycodone, celebrex or cerebyx, for example.

Consumers can now check a website that identifies such drugs, and help prevent a mixup.  Locals who suspect something wrong has happened can contact the Illinois Poison Center.  The IPC also offers tips to avoid poisoning from prescriptions in the first place.

Of course, pharmacies do have extensive protections built into their systems.

"There's a lot of technological support to help them be as safe as possible, including barcoding, even weighing the prescription to make sure it weighs as much as it should" Lambert said. Double- or even triple-checking is common. For example, "One person may pull the prescription of the shelf or enter it into the computer, and another person will verify that the correct drug has been picked off the shelf, and filled into the bottle."

 For the Woodsons, though, the first lesson is that mistakes are possible.

Tiffani Woodson said she'll be keeping a copy of the prescription or asking the pharmacy to make one for her from now on.


Jordan's dad, Tabari Woodson, said "We were very fortunate that something bad didn't happen." 




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