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The NSPA Blog

“Hey, those aren’t my pills! “ A story of medication mix-up and lessons learned.

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Posted on April 19th, 2016 by Teri Dreher, under Prescription Drugs, Take Charge

Josephine*, a 78 year old active grandma of 5, had recently survived a massive heart attack. She had spent 28 days in the Intensive Care Unit, being treated for the heart attack in addition to many complications—respiratory failure, cardiogenic shock and kidney failure that had required dialysis. There were so many miracles—her kidneys recovered, she could breathe on her own, and, most of all, she had survived with her thought processes intact. She had received excellent care!

In order to regain her strength and mobility after her prolonged hospital stay, Josephine was transferred to a private rehab facility. Josephine was so happy to be there. Everyone was nice, the surroundings were beautiful, and there were so many opportunities for her to regain her strength. One morning, the nurse came to give Josephine her morning medications in the little paper cup the nurse always utilized. Josephine studied the pills with total disbelief and exclaimed, “Hey, these aren’t my pills!” The nurse re-checked the medications and realized she had handed her another patient’s morning medications. Thanks to Josephine’s keen awareness that these did not look like her usual pills and were not the correct count of her usual pills, a tragedy was avoided.

Medication errors are a serious issue in both inpatient and outpatient settings. The U.S. Department of Health and Human Service’s Agency for Healthcare Research and Quality reports that 5% of hospitalized patients suffer an adverse drug event, defined as a harm experienced by a patient as a result of exposure to a medication. While some of these adverse events occurred despite the medications being appropriately administered, many are due to errors in medication.

Here’s a little insider info to help you understand how nurses and doctors think about medications. Physicians are trained to write medication orders in a particular format, including all of the necessary information for the right medication to be administered. Nurses are trained to administer medications utilizing the “Six Rights” of medication administration. The six rights include: the right patient (make sure the med is meant for you!), the right medication (many mediation names are very similar. As a common example, Zyrtec is for allergies and Zantac is for stomach problems!), the right dose (examples are units, cc’s or milligrams), the right route (examples: oral, injectable), the right time (time of day), and the right documentation (checking the medication log, the medication order sheet, and the patient’s identity). In addition, the nurse is supposed to verify these rights three times before the medication enters the patient’s body. First, the rights are checked when the med is pulled from the locked cabinet. The second check is when the meds are prepared to be given to the patient and the third time is just before it enters the patient’s body (could be swallowed, an injection, or a patch placed or other routes of administration).

While a patient certainly cannot control all of the reasons for medication errors, here’s what you and your loved ones can do to help avoid medication errors in an inpatient setting, be it a hospital or rehab unit or skilled nursing facility.

1. Know your pills, in every way possible. Know their names, the reason you take them, their “strength” (frequently this is milligrams for pills), and the quantity of pills that you take in total. Josephine fortunately recognized that the quantity and appearance of the pills handed to her were not her usual. A caveat regarding recognizing your pills by sight—you can’t always go by a pill’s appearance. Most facilities are using generic medications whenever possible now, and different manufacturers of the same medicine will produce pills of different shapes and colors than what you are used to. In Josephine’s case, she had been receiving the same meds at the same facility for a couple of weeks, so she had grown accustomed to their appearance. This is obviously quite a bit more difficult in a hospital setting where your meds may be changing daily. In the case where everything is changing daily, please refer to step 2.

2. Have the nurse review every single pill with you before you swallow it. Don’t distract your nurse with small talk or any other conversation besides the meds when he or she is preparing to give you your meds. The nurse administers your meds off of a “medication order sheet” which is a personalized list of your meds and all their specifics. Follow along with the nurse as he or she is referring to your medication order sheet as they prepare to pass you your medications. Have them tell you the name, the strength, the purpose of the medication, and for what time of day it is ordered. The pills should be in their original package and should be shown to you in the package so that you are certain that you are receiving the correct ones.

Many people will read these recommendations and think that this is way beyond the scope of being a patient. It probably is, but won’t you rest easier knowing that you are receiving the correct medications ordered for you? This is called advocating for yourself. If the thought of doing all of this double-checking causes you to have flashbacks of high school chemistry lab or the head-spinning days of algebra, then by all means consider hiring a private, professional healthcare advocate (PPHA) to help oversee your care in the hospital. PPHAs with a nursing or physician background have the education and experience to provide the oversight to help prevent medical errors and improve communication for hospitalized patients.

With over 36 years of clinical experience in Critical Care nursing, home based health care and expertise as a cardiovascular nurse clinician, Teri is well acquainted with the complexities of the modern healthcare system. She has served as a nursing leader, mentor, educator, and consistent patient advocate throughout her career in some of the best hospitals across the country. Her passion to keep the patient at the center of the model of nursing care led her to incorporate NShore Patient Advocates, LLC in 2011, serving clients throughout the northern suburbs of Chicago.

For a no-cost 30 minute initial consultation, please call 847-612-6684 or click here to fill out our online callback request form.