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ISMP Medication Safety Alert


ALWAYS KNOW EXACTLY WHAT YOU PUT IN YOUR MOUTH

Many people have mistaken one drug for another or one liquid for another, swallowed the wrong thing, and suffered or died as a result. That's why it's so important for everyone to look carefully at medication labels, know exactly what is in a medication or drinking cup, and always know exactly what you're putting in your mouth - before swallowing anything

This is illustrated clearly by the story of a recent hospital patient who thought she was drinking juice but mistakenly drank instead a cup of Zenker's Solution - a highly toxic liquid left at her bedside by a physician to preserve tissue after minor bedside surgery. However, the procedure was cancelled. Unfortunately, in this instance a patient died because of human mistakes - the physician's mistake in leaving the cup by the bed and her own mistake in not being completely sure what the cup contained before drinking it.

All human beings make mistakes, even health care professionals. Therefore, don't make tragic and mistaken assumptions that can cost your life. Know exactly what medication you're taking and what it's intended to do. Also, know exactly what you're swallowing. If there is any doubt, read labels and/or ask your health professional to help. If you don't know for sure what's in a prescription bottle, medicine cup, or drinking cup, don't swallow it.

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