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ISMP Medication Safety Alert

Speak up for better patient care!

A 56-year-old man received Glucophage® (metformin) 850 mg instead of 500 mg when he refilled his prescription at his community pharmacy. He recognized that the tablets looked different, but he didn't say anything. He took the medication even though his blood glucose readings were low. He assumed that his glucose meter was broken. Two months later when he refilled his prescription again, the mistake was discovered, but until then, the man felt weak and lacked energy.

Why didn't he speak up sooner?

Unfortunately, for a variety of reasons, some patients hesitate to question medical professionals. Some patients believe that it is disrespectful to question their doctors, nurses and pharmacists. Other patients are simply uncomfortable talking about anything related to their health or medications. Also, unfortunately, some health professionals can be intimidating. No matter what, though, you can help to prevent errors. If something seems wrong, speak up!

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