Feel the Tablet (medication misadventure)

About a year after I graduated pharmacy school, I settled into a very nice hospital pharmacy position in a small community hospital in a mountain town in Northern California.  I am the youngest of eight children, and since I was now officially out of the big house, Mom and Dad felt it time that they sell and move into a more comfortable small house environment.  Mom thought they would travel the state, visiting their children, and find a small house near one of them. 

The first town they visited was the small town in Northern California that my wife and I lived in.  Wouldn’t you know, after a couple of days in our town, Mom had found this cute little house that was no more than 30 feet away from the local Catholic Church, just around the corner from the grocery store, and one block away from the hospital that I worked at.

Over the years of having eight children, Mom had been through quite a few surgeries, including C-sections, gall bladder, heart valve replacement (twice) and a few others I am sure.  When an individual is opened up this much, we are all now aware that the normal fluid that keeps the bowel lubricated begins to deteriorate.  The bowels begin to stick together which leads to adhesions.  

My point here is not to discuss my mother’s medical history, rather, express the point that she was in the position to receive quite a bit of medical care.  Needless to say, the medical and nursing staff at the hospital that I was working at became quite familiar with my mother.  Of course, they also became quite familiar with Dad, being that he was at her side every step of the way.

At the time, I felt like I had gone to pharmacy school specifically to be in a position where I was able to help my Mom with her medications.  At least once weekly, and sometimes daily, I would be at her house helping her set up her medications.  We had a pill box that she would use for the scheduled medications and then the “as needed” medications would be set in a row and she would take them when necessary. 

Mom was pretty darn hip and with it.  She understood her medications, what they did, why she was taking them and I never noticed her express the slightest bit of confusion or frustration with regards to her medication profile.   Because of the adhesions that Mom had developed, she eventually had some of her bowel cut out and had an exterior drainage bag placed.  After a couple months, the surgeon was able to go back in and reconnect her bowels.  This was great; however, she had constant diarrhea and a very difficult time absorbing nutrients.

One of the medications that Mom took to help the diarrhea was called Lomotil.  This medication decreases the propulsion through the GI tract and can quite significantly slow diarrhea.  One morning this was a particular issue.  Mom had taken a Lomotil tablet every 2 or 3 hours throughout the morning and afternoon.  By evening, the diarrhea had not decreased, and she was getting very short of breath and gurgling in her chest.

Here’s the deal, Mom was so familiar with how her tablets felt, she was sure she was taking the correct medication.  The bottles were the same size and the tablets felt similar.  She had not been looking at the label.  Mom had been taking her Digoxin tablets all morning and afternoon.  This overdose significantly decreased her heart function and allowed for a backup of fluid.  Mom was quite weak already, so this didn’t help matters much.  She was admitted to the hospital and stabilized, came home and passed a couple days later comfortably in her own bed.

One would think that a mother of a pharmacist, who was as mentally sharp as they come, would not need to worry about taking the wrong medication. 

It is difficult to imagine how an elderly patient, living on their own, who is prone to slight confusion, can manage their medications without some help. Medication misadventures happen.  We need to be vigilant and have a plan to help prevent these situations. 

Become familiar with using a 7-Day pill box for your maintenance medications.  This will help you assure that you take your maintenance medications on a regular basis.  Please leave your “as needed” medications in their original container so that they remain labeled and are easy to identify. 

Unfortunately, with generic medications, tablet colors and shapes change on a regular basis.  You cannot rely on what the tablet looks like or feels like.  If the appearance ever changes on one of your medications, please call your pharmacy to check to see if you have the correct medication.   

If you have a family member who may fit this profile, please don’t assume they have full understanding of their medication.  Ask them if you may lend them a hand in organizing their medications.  Being pro-active may help them prevent a misadventure.   

You may also be interest in reading the following:
Take charge of your medications (5 guiding principles)
My pills look different
Two Names (generic & trade)


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