Find & Manage Your Patient Assistance Programs
Estimated patient savings $600,000,000.00

Be Alert for Prescription Drug Mistakes

Posted Jun 22nd, 2009 by Trisha Torrey

If your stomach is upset over a period of time, your doctor might prescribe Zantac for you. It’s a drug that helps reduce stomach acid, and may even help heal a stomach ulcer.

Suppose, instead, you have allergy-like symptoms. Your eyes itch, your nose is runny, and your chest is congested. Your doctor might prescribe Zyrtec, an antihistamine that may alleviate those symptoms.

But take a look at those two drug names: Zantac and Zyrtec. When drug names are so similar, doctors and pharmacists may confuse them, and prescribe or dispense the wrong one.

There are hundreds of cases of similar spellings and/or pronunciations being monitored by the U.S. Food and Drug Administration for possible problems. Others include Aciphex (for stomach reflux) and Aricept (for memory), Allegra (for allergies) and Viagra (for erectile dysfunction) or Fosomax (for bone) and Flomax (for veins and arteries). It’s easy to see how they could be confused!

There are other types of medication errors, too. Mistakes may stem from incorrect dosage, meaning too much or too little of the drug is provided. Bad interactions, when a patient already takes a drug that conflicts with a newly prescribed drug, cause problems, too. Or a patient might be given a drug he is allergic too, whether or not the doctor knows about the allergy.

No doctor or pharmacist intentionally makes a mistake. But when medication errors are made, it’s we patients who suffer. In extreme cases, patients die. According to the Institute of Medicine, medication errors kill more than 400,000 Americans each year in hospitals alone. That doesn’t even account for errors made outside the hospital.

Why so many mistakes? Usually it’s human error. Doctors, notorious for bad handwriting, may choose the right drug, but the pharmacist may read it incorrectly. Alternatively, the doctor may get two names mixed up, and the pharmacist dispenses what he reads, not knowing it’s the wrong drug. Or the pharmacist mixes up the names. Sometimes the prescription gets transferred by phone from the doctor’s office to the pharmacy, but the people making or receiving the phone calls make mistakes.

How can you be sure you are getting the right prescription? It’s up to us as patients to be sure we get the right medicine in the right dosage. There are some simple steps you can take to make that confirmation.

First, regardless of your doctor’s penmanship skills, when she writes you a prescription, plan to write down the information yourself, too. Ask her to spell the name of the drug and the manufacturer for you.

Remind your doctor of the various medications you already take. Include any herbs, vitamins, and other over-the-counter preparations you take regularly since some interact negatively with prescribed drugs.

Then ask your doctor the following questions. Recording their answers will help confirm you’re receiving the right drug in the right dose:

  • Why did your doctor prescribe that drug?
  • What form does the drug come in? (liquid? Tablets?)
  • Is there an acceptable generic version?
  • How much and how often should you take it?
  • Should it be taken with, or without, food?
  • Are there any foods or beverages you should avoid while taking the medication? (Some antibiotics are useless if taken with milk, and many drugs interact negatively with alcohol.)
  • Are there any activities you should avoid? (Driving can be dangerous if the drug makes you drowsy.)
  • How long should you take the drug?

Finally, ask about side effects and when you should call the doctor instead of just coping with them. For example, a dry mouth may be a minor side effect, but dehydration would require a call to his office.

Once given your prescription at the pharmacy, compare it to your notes, since some drug problems arise from the dispensing, not the prescribing. Check the container your medicine comes in to be sure it matches what your doctor ordered. Then, ask the pharmacist to verify that what’s inside the container matches its label.

Once you have confirmed you have been given the right drug, make sure you follow your doctor’s dosage instructions closely. Not surprisingly, some medication errors come from the patient side of the equation.

It’s our responsibility as patients to verify the treatments we receive. After all, we’re the ones who suffer if we don’t take that responsibility.


About the author

Trisha Torrey is Every Patient's Advocate. She is a newspaper columnist, radio talk show host, national speaker, and the guide to patient empowerment at

More Artciles by Trisha Torrey →