One of my favorite videos is of a backyard July 4th fireworks display gone wrong: a little dachshund runs up to a lighted Roman Candle, grabs it in its mouth and runs around as fireworks shoot out sideways from the burning tube, scattering the watching crowd. Sometimes getting a new medicine can go sideways on you…
Jane is an 86-year-old just home from the hospital after not being able to catch her breath. At the hospital the doctor diagnosed her with congestive heart failure and changed her water pill to a stronger one to help keep the fluid out of her lungs. She was given a list of her medicines when she was discharged back home and the new medicine was on it, but when I saw her the next day she was starting to have trouble breathing again. Checking her pill bottles, I noticed that she had a new prescription for her old water pill instead of her new one.
“This isn’t the medicine that your hospital paperwork shows you should be taking.”
“I know, but when I asked the pharmacist about it he said that they filled the prescription with exactly what was called in for me. I thought maybe the doctor changed her mind.”
“Maybe. Let me check.”
Calling the pharmacy, I spoke to the pharmacist and discovered that her prescription wasn’t faxed to them but instead was called in.
“Was it called in by the doctor?”
“No, by a nurse at the hospital.”
I then called the doctor who’d prescribed Jane’s new medicine and asked, “Did Jane’s water pill get changed from torsemide back to furosemide?”
“No! I want her taking torsemide, not furosemide. Why?”
“Well, the nurse on the floor called in the new prescription as furosemide. Do you want me to send a new prescription for the torsemide?”
“Yes, please!”
If Jane had taken her paperwork to the pharmacy and showed it to the pharmacist, they wouldn’t have assumed that the doctor changed her mind but instead contacted the doctor to clarify the prescription. Instead, Jane almost ended up back in the hospital with the wrong medicine. She questioned it, but without having the paperwork with her to show the pharmacist, she just assumed the doctor changed it back and accepted the wrong medicine.
Then yesterday, 56 year-old Marjorie came in a for a blood thinner check. She’d gone to the emergency room the previous day with one side of her mouth drooping and trouble talking. Luckily, she got better and the doctors diagnosed a TIA, or transient ischemic attack, due to her blood thinner level being way too low.
“Marjorie, your chart shows that I increased your warfarin dose last week, and changed the tablet size, too. But you’re taking the same dose you were on before.”
“I thought we had changed my dose, but when I picked up my new bottle at the pharmacy the label and tablets inside were different than what you’d told me. I thought you’d changed your mind, so I took it the way the label said.”
When I called Marjorie’s pharmacy they insisted they’d never received any new prescriptions for her, so they refilled her current prescription, which was now the old tablet size and old directions.
“Marjorie, let’s fix this before you really DO have a stroke.”
These days, doctor’s offices send most prescriptions by electronic fax, which records it directly into the patient’s medical chart. Most of these faxes arrive, but when they don’t, it STILL looks like they arrived just fine. With an electronic fax there’s no way to tell the difference between one that arrived at its destination and one that didn’t. I sincerely believe that there’s a black hole in our universe, randomly sucking innocent electronic faxes traveling between doctor’s offices and pharmacies, causing medication mishaps and mayhem.
Here are 3 ways you can protect yourself against your medications going sideways:
1. Make a list of your medicines and update it with any additions and changes. Take it with you whenever you go to the doctor, the hospital, or your pharmacy.
2. If a doctor or other medical provider changes your medicine, get it in writing. Keep this with your current list of medicines and take it to the pharmacy when you pick your prescriptions in case there’s a discrepancy.
3. PLEASE ASK QUESTIONS! Question anything that doesn’t look right to you. With so many people involved and a fax-sucking black hole loose in the universe, omissions and misunderstandings can easily affect your medications. Speak up and question anything that doesn’t look right. Your health and safety may well depend on it.
And watch out for wiener dogs running with fireworks…
