Helping to Prevent Medication Mishaps

by Suzanne Mintz, President/CEO, National Family Caregivers Association

Medication mishaps occur every day. Given the fact that each week, four out of every five U.S.
adults will use a prescription medication, over-the-counter drug (OTC), or dietary supplement –
with nearly one-third of adults taking five or more different medications1 − this is an issue
about which everyone should be aware in order to prevent potentially harmful errors.

In 2006, the Institute of Medicine (IOM) published a report on how to prevent medication errors.
This followed To Err is Human, a 1999 IOM document that identified medication errors
as an issue impacting healthcare safety.

More than 770,000 patients are injured because of medication errors each year and 7,000 people
die each year because of medication errors.2

Preventable medication errors, also known as adverse drug events (ADE) include taking the wrong drug,
incorrect dose, or improper use of a drug. IOM estimates that at least 1.5 million preventable ADEs
occur in the U.S. each year. The true number may be much higher.3

In addition to the cost in human life, ADEs are costly to the healthcare system
and have been estimated to result in total costs (including the expense of additional
care necessitated by the errors, lost income and household productivity, and disability)
of between $17 billion and $29 billion per year in hospitals nationwide.4

Medication mishaps and errors occur most often because not everyone takes their medications as prescribed and in some cases don’t take them at all. In fact, despite the fact that 69 percent of people understand how and when to take a drug, only 31 percent have a good understanding of its potential adverse effects and only 29 percent have a good understanding of its possible interactions.

Because so many people take one or more medications, it is important to be aware of some key information and tips for ensuring the safe use of medications:

Keep up-to-date records of all your medications,
including both prescribed and OTC medications that you purchase without a prescription. The record
should include the name of the medications, what each one is for, their strength, and dosing directions.
While your records can include additional information, covering these basics is critical.

Be aware of occasions when medication mishaps are most likely to occur
and be particularly watchful and cautious at these times.

  • When you/your loved one is taking multiple medications
  • When normal routines are disrupted
  • When new medications are prescribed
  • When a new diagnosis is made
  • When traveling
  • When in the hospital
  • During transitions between settings, hospital to home, for instance
  • During transitions between personnel, such as changes from the day-shift nurse to the night-shift nurse, or from you to a homecare aide
  • When you are fatigued, depressed, or overwhelmed which may result in difficulty remembering things
  • When there is no formal coordination between multiple healthcare providers
  • When using more than one pharmacy

Use your community pharmacist as a resource.

  • Just as you have a regular doctor you go to time and time again, have a single pharmacy fulfill all prescriptions.
  • Establish a relationship with at least one pharmacist at your pharmacy or ask your mail order pharmacy who can help you with questions. Get to know him/her by name.
  • Have the pharmacist help you keep your loved ones and your medication list current. Bring it with you each time you pick up a prescription.
  • If you are not sure what each medication treats, ask the pharmacist to write it on the bottle.
  • Ask about medications that look similar or whose names sound alike.
  • Ask for information about potential interactions between all your/your loved one’s medications, especially when a new one is added or substituted.
  • If you/your loved one is on multiple medications, ask when each should be given to get the best results and avoid potential interactions.

Key questions to ask your doctor or pharmacist about a new medication

  • What is the name of the medication?
  • Why do I/my loved one need this?
  • How much should be taken?
  • Can I/my loved one take it with other medications?
  • How should I/my loved one take it, with or without food, in the morning, etc?
  • How long should I/my loved one stay on the medication?
  • What are the potential side effects and interactions? What symptoms should be looked for?

Web sites worth noting:
This entire site developed by the Association of Health System Pharmacists focuses on medication safety in a very consumer-friendly way. It contains articles on specific topics, an opportunity to sign up for alerts about medication problems, a medication record, and more.
The Institute for Safe Medication Practices is a federally certified patient safety organization. Pamphlets are available on many topics and you can sign up for a medication safety newsletter.
This site includes information from the Centers for Disease Control and Prevention on medication safety. The topics include information relevant to specific patient groups.


  1. IOM Report: Preventing Medication Errors. July 2006. Available at:
    Accessed on 3.29.11.
  2. IOM Report: To Err is Human. Available at:
    Accessed 3.29.11.
  3. IOM Report: Preventing Medication Errors. July 2006. Available at:
    Accessed 3.29.11.
  4. IOM Report: Preventing Medication Errors. July 2006. Available at:
    Accessed 3.29.11.