Four Ways to Avoid Dangerous Drug Errors

By January W. Payne

Posted: January 31, 2008

A new report finds that more than 1,400 common medications were used erroneously between 2003 and 2006—sometimes causing patient harm or death—because the drug name either looked or sounded like that of another drug.

Sometimes, a busy pharmacist misreads a prescription. In other cases, a nurse just hears the doctor wrong. During a press conference announcing the new report, Julius Pham, an emergency and critical care physician at Johns Hopkins University, described a case in which he'd asked that a heart patient be given Levophed, meant to raise blood pressure. But a nurse mistakenly gave the patient Levaquin, an antibiotic, instead. Pham discovered the error after about 10 minutes, when the patient's blood pressure didn't improve.

U.S. News asked United States Pharmacopeia—a private nonprofit organization that promotes the safe use of medications and released the report—for tips on how you can keep yourself from ending up a victim.

• When you get a new prescription, make time to talk with your pharmacist and find out the proper pronunciation of the medication. Knowing how to correctly say the name of the drug may become important if you visit a doctor other than the prescribing physician or get medications in the future through a different pharmacy, advises Diane Cousins, U.S. Pharmacopeia's vice president for healthcare quality and information. Get the correct spelling, too, and keep a list of all of your medications in your wallet or purse.

• Ask your doctor to write the correct indication for use—that is, the medical problem for which you're taking the medication—on the prescription itself. A simple "for sinus" or "for backache" would do the trick, Cousins says. That helps the pharmacist ensure that no mix-ups occur, and if similar information is included on the bottle's label, may help prevent you from confusing it with other medications on your shelf at home, too.

• Check the label when you pick up your prescription. Is it the same medication and dosage your doctor prescribed? Are the directions for taking the medication clear?

• Consult a drug information guide, preferably with color photos for comparison with your own medications. Drugs.com offers such a guide.

Other guides:
Mayo Clinic
MedlinePlus

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