Shadylane I admire you for knowing your meds. I am a pharmacist and take care of people day after day that have no idea what they are taking, what the name of the drug is, or even what it looks like.

I get calls every few days from Drs. and ER rooms asking what medication ms. "Jones" is on. I think in today's society we have become to relaxed on the medications we put in our bodies and leave it up to others to keep track of it for us. But I can empathise with the daughter because this was a new medication and the mother wouldn't know if she was getting the right medication.

A few years back I worked in a hospital....the nightmares I saw made me wonder if the patient had any rights. Every step in the patient care chain had kinks in it and everyone along they way has to own some of the blame.

I would advise anyone who goes into a hospital to always ask about your medication. Bring a current list of your meds or the actual bottles (and send them home so they won't be lost) and once these are placed in your chart for your doctor ask to see it and make sure no transcription errors were made. Always make sure your allergies are up to date on your chart and if you do have allergies make sure your wrist band states the allergy.

I think the story above was written because a drugs name is being changed due to possible confusion with a "cancer drug." I rather doubt that's the real reason. The drug thats being changed is marketed against Nexium, Protonix , Prevacid and others. It has had a poor start gaining market share and years back the same thing happened with Losec which we now know as Prilosec...and we can see how that name change made it the drug it is today. Think of all the free publicity this company will now get by just changing its name and all they have to say its to protect the public.

I have to admit there are drugs that can be confused due to simular sounding names but when you add poor handwriting, poor voice messages, doctors from other countries, and the new e-prescribing system owe much more to errors than sound alike names.

I don't trust hospitals to give the right medication. Also, they tend to give too much medication that can interact with what I need to take. They give their patients medication at night, so the patients will sleep. If I don't take sleeping medicine at home, I don't want it in the hospital.

I've had some horrible interactions - YOU need to make sure your doctor explores any sign of drug reactions or poisoning. If not, seek another opinion. I foolishly didn't because I trusted the doctor.

"She acknowledged that her mother also was taking the anti-anxiety medication Zoloft to calm recent panic attacks"

I'm pretty sure suicide is one of the side effects of Zoloft.

They could have easily found a better example for the article.

There's no doubt that it would come up in a court case.

It is your responsibility to check any medicine that you are taking. (Obviously if they put the wrong medicine in the bottle, or you are given it without the bottle such as in a hospital, then it is not your burden.)

But a 1% mistake rate is really high. 1 in 100 is unacceptable mistakes in any industry.

Some things that could be done immediately:

1) Stop the use of any hand-written prescriptions. Continuing this practice is just stupid. A pharmacist receiving one should just say, "Sorry."

2) Have pharmacies check prescriptions against prescribing guidelines.

3) Require that part of the drug approval process addresses possible name confusion.

Remember that medical malpractice is the fifth leading cause of death in this country. It is not even in the top 10 in any other country in the world.

Chris - Don't forget that the US consumes more prescription drugs than the rest of the world combined. (Although many drugs that are prescription here are sold directly in other countries).

But 1% failure rate is unacceptable.

Chris, I agree. You described intelligent people, whether they are medical personnel or laypeople in a "perfect world." You described physicians who take that extra minute to ensure that they are not wrongly prescribing or overdosing their patients.

Today's patient must assume responsibility for his/her health care and educate him/herself. If a patient doesn't provide his/her physician or pharmacist with a current list of medications, he/she is also at fault.

I'm not a medical professional ... I'm just a person who uses common sense, reads a lot, asks a lot of questions, and doesn't believe in "A med for everything that bothers me."

A few things people should always do. First thing, look at the medication information they stick in the bag, don't just throw it away. These sheets say what the medication is and what it is used for. If you do not have the condition the drug is used forask questions, don't just take the medication. I take several medications and my pharmacist always lets me know if he has changed brands and the pills look different. This is because he knows I will question it otherwise. If your med looks different than what you have been taking ask questions, do not assume it is correct. The drug involved here, Lyrica, is one I am on. Trust me I know what it looks like and would not take something that looked different, there are no generics. Also, before you take a medication, go on-line and do some checking. There are several sites available that will tell you what form a medication comes in and how it is marked. These sites include information on whether it is a capsule, tablet, or liquid; what the color is for each different dosage/strength available; for tablets they give the shape; for tablets and capsules they give the markings that are on the medication (every medication has unique numbers and letters either printed on capsules or inscribed into tablets). These sites will often even tell you if it is safe to split a higher dose pill to take a lower dose or if it is time/controlled released and should not be split. Becoming educated about your medications is your best defense.

The 1.7% error rate is completely unacceptable. Part of this is driven by the shear number of prescriptions Pharmacists and Pharmacy Techs are expected to fill in a day. The greed of the Pharmacies results in too few people trying to fill too many prescriptions. There needs to be protections put in place so that Pharmacists and Pharmacy Techs can lodge complaints without fer of being fired. Of course some of this is due to inattention on the part of the Pharmacists and Techs, trying to do too many things at once (answering phones, answering questions, shooting the breeze, etc.) instead of concentrating on what they are doing.

Another problem is the poor handwriting of the doctors. In this day and age there is no reason that prescriptions can not be printed from a computer and then signed by the doctor. This would eliminate the handwriting problems. Another issue, garbled phone messages are easy to eliminate, set up a system for electronic transmission of prescriptions from the doctor to the pharmacy. This can be done either on-line or by fax. The technology exists for both of these solutions and they would not cost much to implement.

In the hospital do not take anything unless you see it come out of the package and know what it is. Do not be afraid to ask the nurse what they are giving you. If they give you a hard time, insist and tell them you will not take it until they tell you what it is and what it is for. This can save your life. I had a nurse come in to give me a pre-op injection and I asked what was in it. At first I was given a hard time, but I told her I would not allow her to give it to me until I was told. It turned out that the anesthesiologist had not read my chart and had just prescribed his standard. That standard included morphine which my chart clearly said I was not to be given. The nurse got annoyed because she had to chase him down to get the order changed and draw up a new shot, but it saved me some real trouble.

From a personal accountability side, I know when I get my prescriptions what I'm suppose to be getting because my doctor discussed it with me at the time of prescribing it to me. Then at the pharmacy the medications are always gone over with me and I'm asked if I understand what the side effects are and told if I have any questions to call or come back in. How can someone not realize in that instance that something is not right? I mean really I'd notice if they were trying to give me Vicon-C and not Vicodin. Similar in name, but one is for pain management and the other is a vitamin b complex.

Well if you've never taken the medication before, like someone else said, you'd generally assume the doctor and the pharmacist know what they are doing.

That still doesn't excuse the fact that we're each responsible for ourselves. It's easy to check meds online to make sure that we're being prescribed the med for the right reason.

Same thing almost happend to me and too my Mother in seperate hospital stays. Nurse came in with pills we had being taking previously and I knew they weren't right, I had taken care of my Mother in her last few months of her life. Thank Goodness I had been careful or she would have been gone way too soon, but the nurse kept insisting she was right. Finally she went and took another look, she came rushing back full of apoligizes. She had read the script wrong and oh my and sorry sorry sorry. Well I knew better. It was almost the same thing in my case also. And I recieved the wrong medication from my phamacist before, I knew it just didn't look right, and I was right. Somthing needs too change and FAST .

Yes, make the doctor use the generic name of the drug...should be no confusion. The brand name is just for marketing purposes only.

It's just as easy to transpose numbers...

Royal-1845540: Your answer is absolutely correct - using numbers!!! The only thing I would add is that the number be coupled with a name. For the record, there are actually 3 names for every drug - the generic, the market and the chemical. The best answer is for doctors to prescribe by whichever one they're the most comfortable with and be mandated to include a number which is identical for all 3 names. For the assigned number, the best system would be the last few digits of the FDA approval# rather than a simple sequential numbering system. Then it would reference the actual FDA database which has these identifiers already tied together in the 1^st place. After that, it should be regulated that no prescription be filled without a valid cross-check of the name and the number by the licensed pharmacist. PS - I take it Royal-1845540 that you are the organized or mathematical type, too. Being mathematical and organized can solve so many of the problems of the world, don’t you agree?

Randy -- two words for you: citalopram (sit-AL-o-pram) and ceterizine (sit-IR-i-zeen). One is an antidepressant and one is an antihistamine for allergies. Requiring the use of "generic names" is no assurance.

Truly, your comment sounds like a government solution to the problem: people with no knowledge of the field coming up with what they think is an answer when the subject matter is so complex that they don't have a prayer of understanding all that is involved in the problem in the first place. Usually, their ignorant "solution" actually does no flippin' good at all.

Then there's cefdinir, cephazolin, cephalexin, cefixime, cefipime, cefaclor, cefotaxime, cefuroxime, ceftriaxone, ceftazidime. . . Cry "uncle" whenever you want. . . :-)

Bravo Rorn those are just a few of the many many look alike sound alike generic names out there. There are other factors also besides just look alike sound alike such as packaging. I am a pharmacy tech and our pharmacy is in brand generic set up (which most pharmacies now are getting away from) and Lipitor and Lexapro are seperated by a few bottles from each other and both small square bottles and same coloring for the coordinating strenghts and more than once I have had to triple check what I have gotten from the shelf as I will get the wrong one from time to time. I have even dispensed Lexapro for Lipitor and it went out the door that way. That is the most horrifying feeling knowing what you have done. Doing away with handwritten prescriptions is a great idea but the person who would be sending the fax/escript more than likely is not the Dr. himself but a nurse or medical office employee and whats stopping them from just a slight type o. Also the Dr need to know how the medicine should be prescribed and alot they do not prescribe properly.

It's just as easy to transpose numbers...

Barcoding takes all the guesswork out of it.

At my hospital, we do use only generic names, but when meds are sent up to the hospital units, there are certain letters of the name that are capitalized and in a larger font- such as cefDINir, ceFIXime, cefTAZidime (I'm using the ones you already used because it's easier, but ampICILLin and ampHOTERICin are also typed out like that, along with hordes of others). It's a small step, but hopefully it helps combat some problems.

Chelles says, "It's just as easy to transpose numbers..."

Maybe so but if one drug is designated "Cefixime: 4786492136" and another drug is designated "Ceftazidime: 5897142887" it will make it easy to cross check the number with the name. Similar names can be assigned very dissimilar numbers to aid the cross checking.

If a couple of numbers were accidentally switched, the cross check would show that the name of the drug supposedly prescribed was nonsense and a thorough check would then be done by nurses, physicians and pharmacists to verify the correct medication.

For example, if the patient is prescribed "Cefixime: 4786492136" but it was written or typed as "Cefixime: 4786429136" (note the transposition of the "9" and the "2", the drug name plus the drug number still looks nothing like "Ceftazidime: 5897142887", so it would be very difficult to confuse the two different drugs. Also, a check of a pharmacological database would show that a drug named "Cefixime: 4786429136" does not even exist. Medical staff would then do a thorough check to verify what should be the correct medication for the patient.

Also, if letters were added to the number code, e.g "Cefixime: 478Q-649R-213-AS6" compared to "Ceftazidime: B58H-97N1-42C-887", we end up with a rich and extensive coding system that would insure that even the most similarly named drugs had totally dissimilar drug codes.

Ninety-nine percent of all drugs are packaged in containers with bar-codes. On drugs it's called the NDC number & is essentially identical to the UPC code used on most non-prescription packaging. All of the larger national chains use technology to scan this bar-code & compare it to the drug entered in the prescription filling process.

I would also caution against thinking that computer generated scripts will solve all ills. The University of Iowa switched to a system wide computer system & it has caused some problems, mostly relating to finding the drug they actually want to prescribe.

Yes, I was wondering why pharmacists don't scan the upc code to doublecheck. The first person accepting the script could type it in. The person filling should scan the code. There should be a match!

I agree with you about this. Administration error happen far greater than something as simple as a confusion with its name. I couldn't possibly see an error with the drugs Lyrica or Lamictal.

They don't sound alike or look alike. I think its possible it was ordered wrong by the dr or his nurse or transcribed wrong at the pharmacy by the tech or pharmacist. As far as causing suicide ...its listed on its insert as a possibility....but almost all drugs out there are know to do that to some degree and by law it must be reported on the drug's insert. Zoloft (sertriline) is blacked box by the FDA as causing suicide tendencies and suicides. But more than likely the combination of both could have caused this..I guess its up to the lawyers.

RandyTX - That's exactly what I was thinking about Zoloft. Of course the article never mentions that. Typical media. Once they choose a side, all contrary evidence is ommitted.

Coupie -- C'mon, you're now qualified to be the judge of how much money should create perfection in a complicated process? And you're now informed of the variables, including how much of the price comes from the pharmaceutical company vs. how much the "should be perfect" pharmacy makes on each prescription? And just because they work for a pharmacy doesn't mean that the workers share in profits. So you're going to expect perfection from a bunch of barely-above-minimum-wage, overwhelmed-by-the-numbers, understaffed pharmacy techs supervised by one exhausted, overused, overscheduled, undervalued pharmacist? Great. You could be part of the problem.

randytexas that is the most ignorant comment on here. are you kidding me because its overpriced there should be no error. thats absurd. the people in dr's office and pharamcy are human and there will be human error. You obviously havent seen a handwritten prescription from a rushed Dr (who probably didnt listen to the patient to begin with) not to see how lamictal and lyrica could be confused. also 90% of the time people do not look at what has been handed to them from the dr and again at the pharamcy. i encounter people who are on their cell phones when they come and pick up their prescription and they are in too much of a hurry to listen or even ask questions. then they get home take the bottle out of the bag and throw away all of the patient information that was given them and start taking pills. patients need to take responsibility for what goes into their bodies. not to say that the pharmacy staff isnt wrong for making the error. With what Rorn was saying about overworked exhausted pharmasist is right on but places like Safeway only see numbers not pt care. Pharmacies are expected to crank out 400+ scripts with 3 techs and 1 rph who works 12 hours with no lunch and no breaks and the bathroom is in the pharmacy because rph cant be more than so many feet from pharamacy. 400+ scripts means 400+ insurance problems, counseling and that many more people standing in line moaning and groaning about the wait. I find that people will wait longer to sit down in a resturant than they will for their 10 scripts and we wonder why there is a 1% error!

I work in a hospital. I mean, if someone gives you a mortgage document, you read it carefully before you sign it, and that's just your money you risk losing. Pills that someone hands you and tells you to take? I would think you'd read that label pretty carefully, considering it's your body and maybe even your life that's at stake. People (in general- not necessarily this poor woman who unfortunately ended her life) need to start taking more responsibility for themselves and their own lives. That being said, I have never made a medication error in the 4 years I've been at this particular hospital. That's because I take significant time to make sure what I'm doing is 100% correct. So for anyone who complains about waits to see medical professionals (not that that's what this thread is about)... keep that in mind!

smdk...I know you only signed up to post this but I am a pharmacist and have worked in many types of pharmacy settings. I know, after nearly 30 years, what I do and how demanding the profession can be but simple changes can be made to make improvements in the system. Everyone is resistant to change and that would be with patients as well. I never mentioned price...you did. Price shouldn't matter in the equation. But whatever you are doing now I guess you got that little rant out of your system...and the few kind words you mentioned I thank you for but when it comes to what pharmacist do in pharmacies...well, I'm not ignorant.

The article says the owner of the pharmacy is a close family friend, and now the family is considering a lawsuit. I guarantee that close family friend is also completely beside himself, grief-stricken, knowing that this error took place under his (or her) proprietary watch and possibly even under his direction, if he also happens to be the pharmacist (quite common in a small town). The insurance company has probably forbidden any communication with this family, when research now indicates that many medico-legal lawsuits could be resolved by a simple, heartfelt apology. I bet he's just aching to reach out to them, and if allowed to meet with this family, this pharmacy owner would have expressed regret, responsibility, guilt, and grief over her death, if he's truly a close family friend. Anyone out there (rightly or wrongly) felt responsible for another person's death? As a human being, this owner will never be the same again. He will always bear the burden of responsibility in this tragedy, which in this case is appropriate. My guess is that he would instinctively not only offer tearful apology but tell the family what he was doing to ensure it would never happen again to anyone else. Odds are, it wouldn't even remotely occur to him to ask for forgiveness, because he knows he's never, ever, going forgive himself.

That would be great but doctors resist change (just like everyone else). As of now some insurance companies require diagnosis codes to be paid and it takes days to get the doctor or his staff to correct prescriptions. People are somewhat reluctant to wait no matter the reason.

As far as electronically transferred prescriptions the pharmacist transferring the prescription has his/her hands tied because if the original pharmacy made an error the transferring pharmacy will continue that error. The same could go for voice transferring as well. I personally never like the transferring process because of the error potential can be rather high at times...and its not just the name but strength, directions, quantity etal.

e-Prescriptions is being used and that's another nightmare. The program uses pull down menus for Docs to use which results in many errors. I have seen prescriptions ordered for drugs not made anymore, those that are not allowed in the US as of yet, and just the wrong drug selected. So for this program to progress it will needs some serious work.

So basically you're saying people need to pay attention to their work. I wholeheartedly agree. That being said, people who work 16 hour shifts occasionally make errors, even if they are very intelligent and have nothing but the best intentions for their patients. Check the label of your med before you pay for it, and ask if it's the right med for you. That takes like 2 seconds. I mean, if you put a dress on hold at a store and you go back to buy it, and someone hands you a bag and says "here is your dress!", chances are you'd open it to check, right? I know that is a silly example. But the fact that it's so silly (yet very true) makes it even sillier to imagine that people wouldn't check to make sure the substances they are putting inside their bodies are the correct ones.

Beth I can feel your grief...I worked at a hospital and I'd go over to help out the transcriptionist by listening to the doc's and you are right. They can't spell or pronounce many of the drugs and expect you to figure it out...I guess some are too busy to do their patients right and make sure his patients records are correct. I also think if you get it wrong it will be you he/she blames for the chart error. Take care and keep up the hard work.

As an acute care transcriptionist for the last 13 years, I also can tell horror stories about providers who can't pronounce or spell. At the hospital level there is another issue at work here also, the number of providers for whom English is their second language, who we are barely able to understand. We struggle with this every day, and it is getting much worse. The time the doctors used to take spelling things out for us is now considered a luxury, and they are offended if their work is returned to them full of holes from things we just could not understand. This happens all the time with drugs and is especially dangerous in the allergies listing. I completely agree with the suggestion that generics be used exclusively when prescribing and dictating, but retraining doctors to do this would be a challenge to say the least.

At the hospital where I work, we are required to prescribe generic names of all drugs. I think it probably saves a lot of people a lot of trouble.

i saw a tv show with men from jordan talking about the medical training and now being physicians in the usa giving them the ability to kill as many americans as possible. just maybe these are intentional and not accidents. Also the many physicians unable to read and comprehende english is alarming. they should be arrested for medical malpractise. the friends who gave them the medical license as well should be prosecuted. Terrorism comes in many different ways not just by airplanes and bombs.

The old "drug overdose" misdiagnosis is the next medical crisis in ER's.

Wow, you are right on the spot with these comments (were you my teacher?) :)!

I love it!!! Two thumbs up.

Great comment Kathesw! I was given Klonopin instead of clonodine from my pharmacy. Since I am very aware of any meds I take I knew right away it was wrong. I think they are quite similar in their sound. While in the hospital, I made sure the same error wasn't made.

GOD BLESS YOU Kathesw!! In the 'good 'ole days our nursing instructors were the very same way. We were taught that we were dealing with peoples lives and there was no room for error. You are absolutely correct about the 'dumbing down' part too. When it comes to medicine we can't trust anything but our knowledge and our own eyes. Keep on being mean Kathe girl, who knows how many lives it may save!!!!!!!!!!!!!

i hope you and others sue the prescribing physician. I believe this was intentional to cause early death. i think Many people are being murdered intentionaly by physicians they wish to kill the infidels. After watching a tv show with two men from jordan discussing killing as many patients in the usa as they can. This is jihad.

It's one thing to double check your medication, but 15 million perscriptions a year are wrong. This goes deeper than double checking. I don't know which is scarier. 15 million perscription errors a year or that those 15 million errors represent only a small fraction of the medications being taken in this country every year. We are one drugged up nation.

Excellent suggestions. I also have transcribed notes from physicians who were extremely upset that a patient had asked them to explain something. We are supposed to take what they say as the spoken word and most do not want to be bothered with explaining themselves. One doctor was upset because he ended up spending 25 minutes with a patient he was to do surgery on the following week. I personally have spent $120 for a 3 minute office call and $45 strep culture. Most physicians feel they do not have time to discuss their reasons for surgery, reasons for medication, treatment, etc. They are always in a hurry. Maybe it takes something like this for them to slow down in all aspects of their treatment.

We're going to Electronic Medical Records soon, and we'll see; my bet is that there will still be errors - either I'll accidentally click the mouse on the wrong med, or the pharmacist will pull the wrong med off the shelf. You can't automate away human error.

Data entry is only as accurate as the human who enters the data.

Not sure if this is relevant to the article but I do agree with you. Tax, and legalize it. As far as to why it was banned, the history of marijuana prohibition is fascinating . Google it sometimes. Hemp is so versatile, the plant having about 25,000 different uses that Big business (fiber, plastic, lumber) considered it a major threat. Hence, marijuana prohibtion in the 1930's.

I'm all for legalizing pot too, but I don't accept the premise that some stoned idiot has NEVER done something stupid that killed him.

Yeah, some stoner fell asleep with a mouthful of munchies and died, O'Well, better than liver failure from to many pills/hour.

And, pot will have a hard time to get to legalization, because big pharma can't control it's production 100%, it can grow just about anywhere a political candidate can!

I feel sorry for older people because sometimes they don't hear or see or even understand as well. Sometimes they aren't very assertive, they grew up in the era that you did as you were told.. no questions asked. If they don't notice anything amiss or don't have any one to advocate for them, mistakes won't be caught. My mother probably wouldn't have questioned it. She would have just taken them.. "oh well, this is what they gave me... swallow, swallow, gulp, gulp:

Just my opinion avoid ciprofloxain the antibiotic. google flouroquinolones. cipro is a flouroquinolones it can causes damage tears to tendons and/or destroys the blood brain barrier. avoid all flouroquinolones just my opinion .to late for me i have torn tendon to right arm. spouse had torn tendon to achilles.

Why are there 15 million errors a year to begin with? Are we to burden the ineptness of those perscribing them in error onto the patiens? Many of which are the elderly. What if someone has never taken what they have been perscribed and certainly do not know what the effects feel like? How can they know anything about it if it is their first time being perscribed it?

Not everything falls into your category of patient ignorance.

mikeinny who said errors? maybe a few are errors many i believe intentional jihad to kill the infidels. a recent documentary tv show had two men from jordan discussing how many americans they could kill now that they are physicians. also they give medical licenses to friends never requiring english reading and comprehension. appalling the number of physicians who cannot read and comprehende english. The justice department must be infiltrated also because they do nothing to stop the murders.