Many Medications, Many Opportunities for Error

Ralph was the sole caregiver for his wife who was suffering from dementia.  He had health problems himself especially with his vision.  Overall, he was doing a good job balancing household and caregiver duties.  He had designed “his and hers” poster boards of medications to make it easier to fill their pillboxes.  He taped a specific pill on the board and wrote in large letters the name of the medication and when it was to be given, it was much easier to match the pills this way than to try to read the small writing on the prescription bottle weekly.  My biggest concern with this method was what would happen if the pharmacy changes suppliers and the size, color or shape of the medication changes? Would Ralph recognize the change?  Or would a medication error occur?

A recent study observed highly-educated individuals at the average age of 63 and their ability to organize medications for daily use.  They were instructed to place 7 different prescription medications in a weekly pillbox according to the labels on the bottles.  Only 15% of the participants got it right.  Medication errors – including missed, doubled, or incorrectly administered dosages – are more frequent than one might think and highly dangerous.  

Consider the conditions that lead to medication errors:

• The first is the sheer number of meds an elderly person takes. Individuals over the age of 65 are prescribed on average 20 prescriptions a year, not counting over-the-counter medications which only add to the confusion. 

• The second conditions of concern are the visual, cognitive, and dexterity impairments and literacy limitations that can increase the risk of mistakes.

• The third condition of concern is the confusion caused by medication instructions.  A study demonstrated that medications with identical instructions -- “take one tablet by mouth three times a day” -- were arranged incorrectly by nearly one-third of the participants.  There is a new movement to standardize the way prescriptions are written; instead of the label reading “take one every 12 hours” or “take one twice a day,” the new label would be written as  “take one tablet at 8 a.m. and one tablet at 8 p.m.”  Even with these new simplified directions, health literacy should not be assumed.  Supplemental instructions from the physician or pharmacist are needed to ensure understanding.    

Instructions to individuals and caregivers need to be specific and exact.  In the absence of specificity, I have witnessed these medicine misadventures:  rectal suppositories labeled “insert one daily” being swallowed because the patient did not know what a suppository was; an individual instructed to practice injecting insulin by using an orange -- a common practice -- was then eating the orange as he did not understand that he was to inject the insulin into himself; another individual who accidentally overdosed with a pain medication because one caregiver forgot to tell another caregiver that the individual had already been given their pain medication. 

Communication is as always vital. To avoid bad outcomes, it is not enough to ask the patient if he understands; ask him to repeat the instructions and demonstrate what needs to be done, and leave specific instructions of when medications are due or when medications were last given.