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Medication Error: Wrong Dose, Wrong Patient!

By November 13, 2008

Medication Errors: Donít Let This Happen to You!
Dr. Mike shares a story from the news or one of his readers about a medication error.

Earlier this week, my wife had some minor surgery at an ambulatory surgery center at one of the most respected teaching hospitals in the Northeast. While waiting for her to recover, I watched the following set of medication errors take place.

Two men Ė both named John Ė were having surgery, one on his shoulder (John A), and the other on his hand (John B). While in the recovery room, each wife was given a prescription to take to the surgery centerís pharmacy.

Error #1: The doctor for John A wrote a prescription for a narcotic painkiller, but indicated a dose that is not available.

Error #2: The pharmacy gave the prescription back to Johnís wife to bring to the physician to rewrite it for the correct dose. However, the pharmacy clerk gave the prescription to John Bís wife instead of John Aís wife!

The outcome: When John Bís wife returned to the surgical center, the nurse immediately saw the mix-up and called the pharmacy, which had already given John Bís medicine to John Aís wife. It took about 20 minutes to get the wives together and figure out who was supposed to get which medication.

In the meantime, John Aís doctor had left the facility and no one was available to rewrite the prescription for the correct dose. Almost an hour later, when my wife and I left, John Aís doctor had still not answered his page or cell phone. Hopefully, John A has his medication and is healing comfortably.

You can be sure that I carefully checked my wifeís medication before we left for home.

Let Dr. Mike know if you have a story to share about your medication. Leave a comment below or post in the Medication Forum.

Photo © khuonghoang/istockphoto.com

November 17, 2008 at 2:48 pm
(1) Lynn says:

I have been taking a generic form of Ambien for a couple of years. Lately the pills have changed in size and shape three times. My pharmacist says that they are being supplied by different companies but no indication of which companies is on the pill bottle. In addition, there is no indication that a change has been made when I pick up the bottle. How can I be sure that I’m receiving the correct medication?

November 20, 2008 at 11:35 am
(2) drugs says:

Hi Lynn:
From what I can gather, the generic form of Ambien (zolpidem) is manufactured by three different companies. If you are concerned when you pick up your prescription, ask your pharmacist to double check for you. Also, I gave you a link below that shows pictures of the different pills that contain zolpidem.

zolpidem pictures

I hope this helps.

November 24, 2008 at 3:53 pm
(3) Lynn says:

Thanks Mike.

December 29, 2008 at 2:56 pm
(4) ObecendHikeMaynckax says:

itsrxfqwldtgasrzwell, hi admin adn people nice forum indeed. how’s life? hope it’s introduce branch ;)

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