Avoiding Medication Mix-ups

By: Dr. Rob Danoff

Does this sound familiar? You leave a physician's office with a prescription, and as you're driving away in your car, you realize you can't read the doctor's writing. Then, just when you think you've figured out what it's supposed to say, the name of the medication seems to be different from what you thought you heard in the doctor's office. But surely, you say to yourself, the pharmacist will be able to read it because she or he has vast training in reading all sorts of writing and hieroglyphics. Right?

Wrong. Sounds hard to believe, but medication mix-ups are common. In fact, the Food and Drug Administration gets at least 75 reports per month of mix-ups due to similarly named drugs and confusing labels. I heard of a patient who was supposed to be on Allegra (for allergies), but was given Viagra because the doctor's handwriting looked like that word.


Why Do These Medication Mix-ups Happen?

There are three reasons mix-ups occur: the physician, the pharmacist and the patient (yes, even you)! Picture this scenario: The drug company makes a medication with a name similar to others; the doctor quickly writes the prescription; the pharmacist fills it according to what he or she believes is written on the prescription, and the patient picks it up and either disregards the label or figures he's getting a "generic" drug. He goes home and takes the medication that he thought was for his allergies.

How can we reduce the chances of potentially dangerous medication mix-ups? The truth is, we all have to step up to the plate and take responsibility.

First, it would be really helpful if the pharmaceutical companies didn't use similar names for drugs with different actions. For example, the drug Micronor (used for oral contraception) sounds like the medication Midamor (a diuretic), and when poorly written, Desowen (steroid cream) may look like Desogen (for contraception); only the "w" and "g" are different in those names.

Second, physicians need to write prescriptions much more clearly and tell their patients the name of the drug they are to take, and its intended use.

Third, the pharmacist should speak with the patient to ensure that he or she is preparing the right medication for the proper condition.

Lastly, remember that you are the CEO of your own health care, and you as a patient need to take an active role in your treatment plan.

Here's What You Can Do:

For starters, ask your physician to write down the name(s) of the medication(s) you are to take, state what they are for, and note how often you should use them (make sure you can read the writing!). Then, ask your pharmacist the following questions:

  • What are the brand and generic names?
  • What does the pill look like (color, size, shape)?
  • What is the best time to take the medication, and do you take it with or without food?
  • How long do you need to take it?
  • What side effects should you expect, and if they occur, what should you do?
  • What should you do if you miss a dose?
  • Does this medication interact with any of your other medications, supplements, herbal preparations or any foods you eat?
  • Does this medication replace something else you were taking?
  • How should the medication be stored?

As the CEO of your personal health care, it's important that you be informed about each and every medication you take. Please remember that good health care is a team approach. We all need to work together to win the game of good health.

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