ISMP home page Support ISMP ISMP Newsletters ISMP Teleconferences ISMP Online Forums Report a medication error to ISMP Educational programs ISMP online store ISMP consulting services FAQ About ISMP Contact ISMP
 
Print This Page Sitemap

 
 

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.

 

 

Consumer Med Safety

Resources
Main Page
Throw away your old medicines safely
General Advice on Safe Medication Use
Lessons to Be Learned from Past Errors
Preventing Drug Errors in Children
Safe Medicine: ISMP Medication Safety Newsletter for Consumers
Consumer Alerts

 

 

 
Home | Contact UsEmployment  | Legal Notices | Privacy Policy | Help Support ISMP
  Med-ERRS |   ISMP Canada |  ISMP Spain | ISMP Brasil | International Group
Pennsylvania Patient Safety Authority

200 Lakeside Drive, Suite 200, Horsham, PA 19044
Phone: (215) 947-7797,  Fax: (215) 914-1492

© 2009 Institute for Safe Medication Practices. All rights reserved

HON @ Code
Health On the Net Foundation
Health Impact Award
Health Impact Award