The Case of Missing Identity

What is it that tells our mind we are reading one name on a prescription bottle when actually it is a completely different name?   Even more disturbing; why, when a label is old, tattered and not readable, does our brain tell us that we think we know what the contents are when actually we are just guessing?
 
Perhaps we are in pain and we vaguely remember the shape and size of the tablet, maybe it's late and we are tired and we don't pay close enough attention to the label, or we might even be completely distracted, thinking of something else when we are reaching for the pill bottle.
 
For whatever reason, be it the heat of summer, vacation schedules, or just the recent full moon, I have recently been involved with two such situations.  It is not important to go into the details of each situation; however, both ended with phone calls to the pharmacy after a series of unwanted and unexplained side effects.
 
Fortunately, both situations ended without visits to the hospital; however, they were both completely avoidable had they been following a few simple rules.
 
  1. Know the names of each of your medications.
  2. Know why you take each of your medications.
  3. Before your take your medication or fill your pill box, verify that the medication description on the label matches the description of the tablet in the bottle.
  4. If the description does not match, or you cannot read the label, call the pharmacy.
 
In the early 90's I was regularly involved in helping my Mom set up her prescriptions.  Mom was not unfamiliar with hospitals, having had eight children and multiple surgeries throughout her life.  My wife and I were intimately involved with my parent's life and would commonly stop by their house to visit, while also assuring the medications were all in order.
 
My point is, even with a pharmacist son setting up the medications on a scheduled basis, issues happen.  Mom had been having some severe gastrointestinal issues and had been prescribed a potent anti-diarrheal medication to treat the situation.  These tablets are small white round tablets that look like quite a few other small white round tablets.  Over the course of 48 hours Mom inadvertently took seven or eight heart pills, thinking they were the anti-diarrhea pills, in a failing attempt to stop her diarrhea. 
 
The bottle was labeled properly and the correct pills were in the bottle; however, she stated that she was sure she had the right medication because if looked and felt like what she was familiar with.  This event did result in a hospitalization.
 
As you can see, this topic has a deep meaning for me.  Please, take the time to follow the four simple rules of medication identification listed above.  It may mean the difference between life and death.
 
Thanks
Steve
 
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