Patient Safety and Medication Errors

When we are admitted to a hospital, we place our lives in the hands of the team providing our care.  We trust that the system works.  Most of us haven't taken the time, prior to admission, to research the hospital ranking statistics and evaluate how many medical errors this particular hospital makes in any given month. 

It is not our thought, when we are being put under anesthesia, to ask the facility if they are using a Computerized Prescriber Order Entry (CPOE) system.  We probably haven't read the most recent studies that show hospitals which utilize CPOE systems to process medication orders may decrease their medication error rate by 48%. 

Finally, I am sure we are not aware that an estimated 210,000 and possibly upwards of 400,000 deaths in hospitals each year may be attributable to preventable medical adverse events. 

Please read the full article at RxEconsult:


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Pharmacist's and their Labels

Take home message:  If your doctors ever changes your dose of medication while you are at the office, please ask them to forward the new directions to your pharmacy so they will be prepared for you when you show up early to get your prescription.

"Sir, it is too early to refill your prescription.  It was just 2 weeks ago that I filled your prescription for a full month supply of medication."

"Yes, I know, but at my last visit, my doctor told me to double my dose….."

Pharmacists do much more than just put labels on prescription packages.  That said, we do put labels on prescriptions, and quite a few I might add; we take this part of our job very seriously.  These labels, as simple as the process may seem, are a tremendous wealth of information, and they better well be accurate!

We guard our labels.  Every piece of information on the label, from the patients name, physicians name, directions, medication name, description of medication and all of the other required documentation is verified by a pharmacist each and every time a prescription is dispensed.  This is not just a retail pharmacy deal; labels go on all of the medications in hospitals, skilled nursing facilities, i.v. solutions and anywhere else a medication is prepared to be administered or dispensed to a patient.

An issue we run into regularly in retail pharmacy is someone needing to refill their prescription, when according to our records, they should still have at least two weeks of medication remaining.  At this point, part of what we do in the pharmacy is play detective.  We will engage the patient in a conversation and do our best to figure out what happened with the rest of the medication. 

Over the years I have come across many different scenarios explaining why a medication container has come up short; however, one situation that comes up over and over again is the one I described at the beginning of this discussion.  A patients' doctor has increased their dose and no one has notified the pharmacy.  According to our records, the directions on the label of the prescription are not the same as how the patient is now taking their medication. 

At this point, the filling of the prescription is put on hold until we can contact the prescribing physician and clarify the directions.  I understand the patient is here explaining to me what the doctor told them to do, however, I cannot change the prescription label without an order from the doctor.  If the doctor is not readily available, we will make sure the patient has enough medication to hold them over till tomorrow while we wait for the physician to follow-up with us.


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Yes, It's Free Medication Education

I have used this quote in the past and I am sure I will use it again someday.
This is an incredibly tall order, and one that is difficult to always meet in the ever busy and fiscal conscious health care setting.  It is possible that patients may be discharged from a hospital or pick up their prescription from a pharmacy and not be completely educated about their medication regimen when they get home.

Not only may a patient have a difficult time organizing and understanding their new medication treatment plan, they may also be confused as to what questions are important to seek answers to.  Patients have a few alternatives as to how they may achieve appropriate medication education awareness.

·         Just take the medication and see what happens.
·         Read the lengthy medication leaflets.
·         Try to come up with some questions and call their pharmacist or other health care provider.
·         Call a family member (works well if their brother is a pharmacist).
·         Search on the internet for a "trustworthy" source and then filter the information.
·         Listen to a Medication Specific Counseling SessionTM on

AudibleRxTM provides medication education in digital/audio format.  After listening to a 6-8 minute counseling session a patient or caregiver will have a clear idea of what they do and don't know about their medications and be in a clear position to take educated questions back to their own health care provider.

The good news is, AudibleRxTM is now FREE for individual users. 
The counseling sessions may be accessed at the AudibleRxTM website through one of the four available versions (Web Platform, Android App, iPhone App, HTML5 Web App).

AudibleRxTM is free for personal use; however, it is not to be used for institutional, retail, insurance, clinic or employer provided patient education without first obtaining licensing rights.  Please contact AudibleRxTM for more information.

As always, remember, AudibleRxTM does not replace the important face-to-face interaction with your own pharmacist.  We hope to educate you about your medications so you will be motivated to participate in your own pharmaceutical regimen.


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Decrease Constipation

Today I have the opportunity to have a discussion with a group at one of our local retirement facilities about constipation.  Of course, our discussion will include more than is listed on this handout; however, these three items are paramount.  If we consume adequate fiber and drink plenty of water, maintain plenty of physical activity, and do our best to move our bowels when we feel the urge, we will significantly decrease the chances of constipation!
1.             Fiber and Water

2.             Physical Activity 

3.           Heed the Urge

·      Normal may be from 3 movements/day to 3 movements/week. 

·      What is normal for you?

·      Do not self-treat for more than 5-7 days.

·      Consult your Pharmacist or Doctor for recommendations on what the best medication treatment is for you.


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