HAVE A PRESCRIPTION? TALK TO A PHARMACIST
A close call involving a prescription for an over-the-the
counter product, filled at a health food store, underscores
the need for clear interpretation and advice on all prescriptions.
Here's the story.
An elderly woman who was experiencing a variety of infections
had been treated with antibiotics over several months. Because
of the antibiotic use, she began to suffer from diarrhea.
Her doctor told her to eat yogurt for 10 days to stop the
diarrhea. However, the woman disliked the taste of yogurt
and stopped after only a few days.
She again visited her doctor about the continuing diarrhea.
He substituted a prescription for Lactinex® (lactobacillus
acidophilus and lactobacillus bulgaricus) and told her she
could get the over-the-counter product at a health food store,
since it was not a prescription-only product.
The woman, who was nearly blind, gave the prescription to
the clerk in the health food store to read and fill. Instead
of "1 capsule, 4 times a day," the health store clerk misread
the prescription as "7 tablets, 4 times a day" - nearly double
the label's maximum dose. At the woman's request, the clerk
clearly rewrote what he believed to be the doctor's instructions,
directing her to take a whopping 28 tablets a day instead
of the appropriate four tablets per day. After only one day
of this larger dosage, the woman began suffering severe nausea
and her diarrhea grew much worse than it had been.
Fortunately, the woman's son was a pharmacist and discovered
the clerk's error in interpreting the physician's poor penmanship.
The patient was then treated with fluids and appropriate medication
to recover completely. Yet such incidents remind us that use
of all medication, whether over-the-counter or prescription,
can have unintended and sometimes dangerous outcomes. Therefore,
all medication must be interpreted and used very carefully.
Visiting a qualified pharmacist for advice on any medication
use can be an important safeguard. Pharmacists further the
work of your physician and other members of the health care
team by using their highly specialized education and experience
to recognize and guard against potential medication mishaps.
Further, patients and their families can be an important
safeguard in medication use by making sure that they clearly
understand the doctor's medication orders before having the
prescription filled. While still in the doctor's office, the
patient or caregiver should write out and repeat for accuracy
the new medication and dose. This new medication should be
added to a full and up-to-date list that the patient keeps
of all drugs he or she may be taking.
Institute for Safe Medication Practices