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Avoiding Mistakes When Taking Medications

By Jason Poquette, BPharm, R.Ph

It was Albert Einstein who once said “a person who never made a mistake never tried anything new.” This may be true. But some mistakes are more costly and dangerous than others. And according to research recently published in the journal Clinical Toxicology, mistakes made by patients at home while taking medication are becoming more common. In fact, the researchers noticed a 100% increase in the number of serious medication errors during the 13-year study period from 2000 to 2012.

Medication mistakes actually occur at an alarming rate across the country. Such mistakes include, according to the study authors, “any unintentional deviation from a proper therapeutic regimen that results in the wrong dose, incorrect route of administration, administration to the wrong person or administration of the wrong substance.” Together they add up to about 1.5 million errors per year, or about 171 errors per hour. Yikes! Most studies to date have looked only at medication errors occurring in hospital settings.

The interesting thing about this study is that they were looking exclusively at mistakes with medications made in places where most of us actually take them: at home, work or school. They reviewed data reported to US Poison Control Centers who categorize information about the severity and type of medication-related errors. The study specifically looked at the “serious” medication errors, of which there were 67,603 occurrences.

What are the most common mistakes we are making when it comes to taking our medications? Nearly 20% of the reported errors were related to taking the wrong dose. An example of taking the wrong dose would be taking 2 tablets instead of the prescribed 1 tablet daily. The next most common mistake occurred when patients took the entirely wrong medication (19%). Finally, about 16% of the reported errors were related to taking the dose twice, presumably due to forgetting that the dose had already been taken.

As a pharmacist, this kind of information is not especially encouraging. It may suggest that we are not doing a great job as healthcare professionals explaining to patients how to take their mediation safely. To the degree this is true, those of us in healthcare need to focus on spending more time with our patients going over and reviewing medication dosages. Time pressures and workloads are surely factors that complicate this whole process. But in the end we need to make the time and talk to our patients.

The results may also indicate that taking medication appropriately is simply getting more complicated. Many patients, especially seniors, are on multiple medications. I personally have patients who are on a couple dozen or more different medications every day. Keeping this straight is no easy task.   It is easy to see how forgetting whether a dose was taken or accidentally taking the wrong tablet could sometimes occur.

On average, there were about 5200 medication-related errors per year in the home which resulted in a “serious medical outcome.” About 1/3 of these required hospitalization. Thankfully less than 1% of the serious errors resulted in a fatality, but even that number is too high given that, according to the study, “most non-health care facility medication errors are preventable.”

I remember distinctly my toxicology profession in college reminding us that all medications, even the best and safest, can be dangerous if taken wrong. “The dose,” he would frequently say, “determines the poison.”

Both patients and providers would be wise to listen carefully to the results of this research. Take a little extra time when taking your pills today. Getting it right might save your life. Remember, even Einstein made mistakes.