What You Need to Know . . .
Avoiding Medical Errors and Protecting Your Safety
CONTENTS:
• What the Research Tells Us
• What's Being Done About the Problem?
• What You Can Do
• Resources
Published by the National Women's Health Resource Center
March 2004
A pharmacist cannot read the doctor's handwriting on a prescription and dispenses the wrong medication dosage. A doctor reading a mammogram misses a suspicious area that later turns out to be breast cancer-and that probably would have been picked up if a second doctor had looked at it. • Generic names. Some medications may be ordered by their brand name and labeled by their generic name. Be sure to ask if the medication has another name to prevent taking duplicate therapy.
These are just two examples of the many different kinds of medical errors that occur throughout our health care system. In a groundbreaking report on the problem published five years ago, the Institute of Medicine (IOM) of the National Academies, which provides unbiased, evidence-based, and authoritative information and advice concerning health and science policy, defined an "error" as "the failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim."

Some medical errors cause serious harm to patients and some don't, but they all have one thing in common: they are preventable. Most errors happen not because a health care professional is incompetent, but because there is a breakdown or flaw in the medical system, or a communication error, with no mechanism or process in place to catch the mistake.

What the Research Tells Us

Recent studies focusing just on medication errors suggest that there is much room for improvement. According to the U.S. Pharmacopeia, which sets standards for the use and quality of medicines in this country, the 482 hospitals and health care systems in its database reported more than 190,000 medication errors in 2002. And a study of 50 pharmacies in six cities published last spring concluded that a pharmacy dispensing 250 prescriptions daily was likely to make four errors per day.

What's Being Done About the Problem?

Some hospitals have begun to adopt new technology designed to guard against errors, such as new computerized prescribing systems that assist physicians when ordering medications and require health care professionals to type in prescriptions rather than provide handwritten ones.

But real improvement in the situation will take money and time-both of which are in short supply.

 What You Can Do

Until the system improves, consumers need to protect themselves against medical errors by being informed. That means asking questions about your care. You have a right to know and understand all the details.

Take these steps to be informed:

• Do not hesitate to ask questions if you do not understand directions or the reason for a procedure or medication.
• If too much medical jargon is being used to explain your health care needs, ask for an explanation in simpler terms.
• Ask the health care professional to write down information for you so that you can bring it home with you and/or ask a relative or friend to review with you.

If you are not able or wish not to take these steps, consider asking a relative or friend to do them for you. Also, plan to speak up for loved ones who cannot speak for themselves, such as the elderly and children.

The following tips are offered to help you avoid some of the most common medical errors.

Medication Errors

Medication errors can happen for a wide range of reasons, from poor handwriting on a prescription to a mix-up between two patients in the hospital.

To avoid such problems in the doctor's office or pharmacy, you should:

• Make sure you can read the prescription before leaving the health care professional's office. Ask how it should be taken (by mouth, in the ear, in the eye, etc.).
• Ask about brand substitutions. Often, there are different brands of the same medication. Ask your health care professional if other brands, or a generic version, can be substituted, and if so, write those names down as well.

• Watch out for sound-alike names. Medications for very different conditions often have similar names. Consider asking your health care professional to write the name of your condition on the prescription to decrease the chances of an accidental mix-up.
• Be aware of potentially dangerous drug interactions. Tell your health care professional about any other medications (both over-the-counter, prescription and herbal remedies) you are taking.
• Keep a written record for yourself. Write down the recommended drug and dosage before handing the prescription over to the pharmacist (or having the prescription called in by phone).
• Read the label. Double-check the bottle label to make sure the prescription was filled correctly. Read the drug information handout to learn about how to take the medication, side effects and proper storages before leaving the pharmacy, so you can ask any questions.
• Use the dropper or dose cup or measuring spoon for liquid medications. Ask the pharmacist to recommend a device. A teaspoon or tablespoon is not always an accurate measure.
• Keep medications in the original bottles. Do not mix medications or remove them from their original bottles.
• Side effect. Ask what side effects you may experience and when to call for advice. Some side effects may lead to more harm or may cause you to discontinue the medication prematurely.
• In doubt? Call your professional. Do not take the medicine until all of your questions are answered.

If you (or a loved one), is a patient in a hospital or clinic, you should:

• State your name and the name of the medication before taking anything, or allowing someone to attach you up to an IV. For IV medication, verify the name of the drug and the dosage before the bag is hooked up. If possible, ask your health care professional to write down the medications and their dosages for you in advance.
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