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ISMP Medication Safety Alert


Why it's important to read the labels of your medications

Even if you've heard it before, it bears repeating: read the label before you take any medication. A 69-year-old woman took 12 tablets of Valium® (diazepam) 5 mg instead of 12 tablets of Tri-Mox® (amoxicillin) 250 mg because she grabbed the wrong bottle. The woman, who has a heart murmur, was supposed to take Tri-Mox 3 g before a dental appointment. The pharmacy where she filled the prescription did not have the Tri-Mox 500 mg tablets, of which she usually took six tablets. Instead, the pharmacy filled her prescription with Tri-Mox 250 mg tablets, and the pharmacist told her to take 12 tablets to make the 3 g dose. Because her appointment was not for a few days, she put the bottle in the medicine cabinet at home. Before she left for her dental appointment, she accidentally picked the Valium bottle instead of the Tri-Mox bottle from the medicine cabinet and took 12 tablets. Then, while driving to her appointment, she blacked out, and her car hit a tree. Fortunately, she was not seriously injured. At the emergency room, during the accident investigation, Valium was found in her urine specimen, and her mistake was discovered. Most prescription bottles look alike-they're usually amber colored with white caps and labels. For that reason, you have to read the labels every time you take a medication. This accident didn't have to happen, but the rest of us should learn the lesson, too.

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