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THE doctor prescribed chloromphenicol, a prescription drug for typhoid. But when the nurse wrote down the prescription, it became chloroquine, a medicine for malaria. And that act of the nurse changed the course of young Harjot Ahluwalia’s and his parents’ lives. The reaction to the drug was so severe that it caused irreparable damage to young Harjot’s brain cells. Here, it was not just the wrong medication, it was also the high adult dosage given to the child, without even a test dose that caused the severe adverse reaction (Spring Meadows Hospital vs Harjot Singh Ahluwalia). According to the Food and Drug Administration (FDA), USA, about 10 per cent of all medication errors reportedly result from drug-name confusion. Take the case of an 8-year-old child who died after receiving methadone instead of methylphenidate, a drug used to treat attention-deficit disorders. There are many such reported cases before the FDA: a 50-year-old woman, for example, was hospitalised after taking Flomax, used to treat the symptoms of an enlarged prostate, instead of Volmax, used to relieve bronchospasm. Similarly, Atropine has been confused with Akrapine, says the FDA. To minimise confusion between drug names that look or sound alike, the FDA reviews about 400 brand names a year before they are marketed. About one-third is rejected. Sometimes, even after a drug name is approved, the FDA gets the name changed. As it happened when the diabetes drug Amaryl was being confused with the Alzheimer’s medication Reminyl, and one person died. Now the Alzheimer’s medicine is called Razadyne. Medicines cure, but they can also kill or cause severe adverse reactions, if a wrong medicine is administered or if the dosage is all wrong. And this can happen at various levels — the doctor can make a mistake, so also the nurse. There are also cases where the pharmacist has misread the prescription of the doctor and sold the wrong medicine. Why does it happen? Carelessness, illegible handwriting, unfamiliarity with new drugs, similar-sounding brand names, similar-sounding generic or generic and brand names, look-alike packaging, are some of the reasons. In addition, medication errors can also occur on account of abbreviations, acronyms, dose designations, and other symbols used in medication prescribing. In the US, the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) notes that patients’ medications have been stopped prematurely when D/C —intended to mean discharge — was misinterpreted as discontinue. Similarly, the Institute for Safe Medication Practice (ISMP), a US-based non-profit organisation working towards preventing adverse drug events such as this, lists out several such cases. For example, where the physician had prescribed administration of Insulin 15 units am plus 6 units pm, the nurse read the plus sign as 4 and thus 6 units became 46 units. In another case, a patient died after receiving 60 units of Insulin — the nurse misread 6U (units) of insulin as 60. In India, too, the problem has to be tackled on several fronts. The regulator, the Drug Control Department, has to ensure that similar-sounding medicines are not marketed. It must also ensure that pharmaceutical companies do not market drugs with look-alike packaging. The pharmaceutical companies, on their part, should ensure that the name of the drug — both brand name and the generic name — is printed in such a way that they are clearly legible. They must also keep in mind the fact that a large percentage of medicines are consumed by the elderly, whose eyesight is poor. Doctors, on their part, should communicate better with patients and ensure that prescriptions are written in a manner that is easily read and understood. Where abbreviations are used, they must explain to the patient what they mean. Pharmacists or dispensing chemists also have a role to play. They should not only read the prescription carefully, but also ensure that what they are dispensing is the right medication. Pharmacists can also help by keeping look-alike, sound-alike products separated from one another on pharmacy shelves and also by crosschecking with the doctor, names or information that is not clear. Meanwhile, here are some
suggestions to consumers to reduce medication errors: get the doctor to
write the generic name as well as the brand name. And write the
prescription in capital letters so that there is no misinterpretation.
Get the doctor to also include the purpose for which the medication is
prescribed. In fact you must talk to your doctor and ensure that you
have a complete understanding about the prescription, the dosage, when
to take the drug and for how long. Always crosscheck the prescription
with the medicine dispensed by the chemist. Make sure that you have the
right medicine. If you have any doubts, talk to your doctor. |
