Medication errors harm millions a year

McClatchy Newspapers

KANSAS CITY, Mo. — Slurred speech. Disorientation. Memory loss. Morris Ganaden thought he was having a stroke.

So did doctors in two emergency rooms, but brain scans and other tests turned up nothing wrong.

Turns out Ganaden, 75, wasn’t having a stroke. He was taking the wrong pills.

Despite efforts to prevent medication errors, mix-ups such as this are occurring across the country with alarming frequency.

Ganaden, of Independence, Mo., was supposed to be taking a common thyroid medication called Synthroid. But a drugstore mistakenly refilled his prescription with Seroquel, a powerful antipsychotic that is used to treat symptoms of schizophrenia and bipolar disorder.

Synthroid tablets are yellow and round. So are the larger Seroquel tablets. Ganaden didn’t detect the difference before he had popped the pills.

“If it’s in the bottle, you don’t pay too much attention to what it is,” said Ganaden, a retired engineer. “If it was oblong, I probably would have noticed, but it was round and yellow.”

Medication errors — wrong drug, incorrect dose or improper use — harm at least 1.5 million people every year, according to the Institute of Medicine. Confusion caused by drugs with similar names accounts for up to 25 percent of the reported errors.

Heartburn drug Zantac gets mixed up with antihistamine Zyrtec. Prostate drug Flomax gets confused with asthma drug Volmax.

Premature infants with intravenous lines have received insulin instead of the blood thinner heparin. Patients with epilepsy have received the AIDS drug Keletra, instead of the anti-seizure drug Keppra. Cancer patients have gotten the wrong chemotherapy when Taxotere and Taxol were confused.

“Unfortunately, these kinds of errors are commonplace,” said Jack Fincham, a professor at the University of Missouri-Kansas City’s School of Pharmacy. “It’s the sheer number of drugs — the tablets, the capsules — that look and sound alike. There’s lots of room for errors.”

Health-care organizations and federal regulators are working to prevent these kinds of mistakes, but the job is daunting.

In a 2008 report, U.S. Pharmacopeia, the organization that sets standards for drugs, found 1,470 drugs implicated in medication errors, some lethal, caused by brand names or generic names that sounded or looked alike.

Together, these drugs created more than 3,000 mixed-up pairs, nearly twice the number the organization counted in 2004.

Many initiatives have been launched to reduce medication errors, but their effects are hard to gauge.

Experts say consumers can do a lot to make sure they are getting the right drugs.

For example: Make sure your physician writes both the brand name and generic name on each prescription, along with the purpose of the drug.

At the pharmacy, accept the counseling offered by the pharmacist. With the pharmacist, check the labels on the bottles and open them to make sure the right pills are inside.

“Most consumers are in a rush and don’t see a value to it,” Cohen said. “And they’re wrong.”