RN HEALTHCARE ADVOCATE CASE REVIEW: Prescriptions, Your Pharmacist and Best Ways to Avoid Mistakes

Rx imageIf you’ve ever gotten the wrong prescription, you know that it can be costly and a nuisance at the very least. But did you know that medication errors can cause harm and even be fatal? Medication errors that cause harm are called “adverse drug events.” This can be due to reactions from medications that are not supposed to be taken together, incorrect dosage instructions or allergic reactions. Overdoses and adverse reactions to prescriptions are the worst case scenario. There are a sea of other scenarios that involve non-life-threatening problems or are simply time-consuming to correct.

Most prescription medication mistakes boil down to human error. Doctors may prescribe the wrong medication or sometimes the pharmacist mixes up the names of two medications and dispenses the wrong prescription. A doctor’s handwriting may be illegible and the pharmacist reads it incorrectly. There are also erroneous prescribing faults on the part of a doctor which can result in harm to a patient. According to the Mayo Clinic, mistakes in prescribing, dispensing and administering medications injure more than 1 million people a year in the United States. These incidents are preventable—and fortunately, you can take a proactive approach to make sure your prescriptions are written and filled correctly.

Today Amy is our guest and she is sharing with us her experience with receiving the wrong medication from her Pharmacy:

My Recent Experience with Wrong Rx—Doctor Error

Here is a scenario I ran into: I went to my primary care physician for a rash around my mouth—which was later diagnosed as Perioral Dermatitis. My PCP prescribed Metronidazole cream but cautioned that he wasn’t familiar with this condition and I would probably need to see a specialist. I realized after a few days that the “Metro” cream was not treating my rash. So, I was referred to a dermatologist. The dermatologist made a note of the ineffective treatment cream and proceeded to diagnose the rash and prescribe me Hydrocortisone ointment, 2.5%. This topical ointment cleared up the rash almost overnight. On my follow-up visit to the dermatologist, he advised that I could continue the ointment and he would email 2 refills to my pharmacy. I picked up the prescription from the pharmacy without checking the bag and assumed it was the Hydrocortisone cream. However, when I opened the bag to use the ointment later, I realized it was Metronidazole cream—the original ineffective cream!

The pharmacist explained that he simply filled the order the doctor emailed to him. I realized that the doctor sent this cream in error, so I called his office to inquire about it. I spoke to a medical assistant who told me that according to his chart, Metronidazole cream was the correct prescription. At this point, I sought the advice of Donna—MVLNC private healthcare advocate. She advised that I should go back to the dermatologist’s office and speak to the doctor himself. Donna also explained the importance of getting a physical copy of the prescription with the name and strength of the medicine as well as dosage instructions for my personal records. If I wasn’t able to see the doctor, Donna advised that I should speak to an RN about the mix-up as opposed to a medical assistant, who may not be able to assess medications and their differences. This was extremely helpful advice—as it was the only way to get to the bottom of the prescription error and correct it.

Make Sure you Receive the Right Medication Before Leaving the Pharmacy

  • Be sure you get a thorough consultation from your doctor about what is being prescribed, what the dosage is, how often you will take it and what you can expect from taking the drug.
  • If the doctor’s office plans to phone in your prescription to the pharmacy, ask for a written copy, too. Take the time to review it to ensure it covers the same prescription your doctor has described. Once you get to the pharmacy, a written copy will help you confirm you are getting the right medication.
  • Usually your prescription will be handed to you, bagged and ready to go. Before you leave the pharmacy—open the bag, and check to be sure your name is on the prescription.
  • Read the label and make sure it says what you expect based on the information your doctor gave you. Check to be sure you have the right drug, in the right dose, in the right amount.
  • If there are any discrepancies, ask to speak with the pharmacist. Donna advises: make sure it is indeed the pharmacist you are talking to! Pharmacists can question prescriptions and doctor’s orders. A pharmacy tech usually just fills the orders and may not be able to solve a problem or answer medical questions.

Medication errors are serious business—doctors and pharmacists need to be made aware of a mistake no matter how inconsequential it may seem. But more importantly, it is up to you (the patient) to monitor your medication usage. Not only should you question possible drug interactions at the doctor’s office and pharmacy, always keep hard copies of your prescriptions on file for your own records. If you have any questions about drug interactions, prescription errors or problems filling prescriptions, contact MVLNC to get private healthcare advocacy advice.

Stay Tuned for More Tips on How to Prevent Errors

Unfortunately on a daily and weekly basis, I have been working with these types of scenarios. The purpose of moving to computer entry of orders was to help minimize these mistakes. However, humans make mistakes and computers have glitches. Check back with us for more tips on preventing medications errors at home.

Donna M. Post RN CLNC LNCP-C, CHA

“Navigating Your Way Through Our Healthcare System”

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This entry was posted in Clinical Corner, General, Nursing, Patient Advocacy, Private Healthcare Advocate, Senior Care Management, Uncategorized. Bookmark the permalink.

One Response to RN HEALTHCARE ADVOCATE CASE REVIEW: Prescriptions, Your Pharmacist and Best Ways to Avoid Mistakes

  1. Pingback: Medications that help but what it takes to get them Part 2 of 2 | braininjuryselfrehabilitation

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