Medication mix-ups a cause for concern among seniors


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If there is one thing I’ve learned while working as a patient-safety champion over the last 12 years it is simply this: medication mix-ups happen far more often than people realize.

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Hey there, time traveller!
This article was published 28/10/2016 (2221 days ago), so information in it may no longer be current.

If there is one thing I’ve learned while working as a patient-safety champion over the last 12 years it is simply this: medication mix-ups happen far more often than people realize.

I was reminded of that lesson again recently while I was reviewing some material in preparation for Canadian Patient Safety Week, which ends today.

It involved a 72-year-old woman on home care who was finding it difficult to live her life to the fullest because she experienced extreme dizzy spells when standing or walking.

Eventually, one of her home care workers decided to sit down with the woman and go through all of her medications, a process known as medication reconciliation.

As it turned out, Mrs. A’s medications were the source of her problem. Somewhere along the line, she had been prescribed multiple blood pressure medications, and it was the combination of different pills that was actually at the root of her deteriorating health.

After consulting with a doctor, Mrs. A’s medications were changed, her blood pressure became stable and her health improved to the point she no longer needed home nursing care.

Yes, medication mix-ups happen, and they happen often.

Consider these numbers:

An estimated 40 to 50 per cent of patients in hospital and 40 per cent of patients discharged from hospital experience potential medication errors that could lead to health issues. In Manitoba, it is estimated medication-related incidents are the third leading cause of all harmful patient incidents. These injuries can result in emergency department visits, admission to hospital and death.

Seniors are particularly vulnerable to medication mix-ups.

In 2008, the Canadian Institute of Health Information found two-thirds of seniors were on five or more drugs, and 21 per cent of these took at least 10 drugs. It’s easy to see how the average person can lose track of what they are taking and how often.

Fortunately, there are ways to reduce the risk of harm from medication mix-ups.

One is to ask questions. The Institute for Safe Medication Practices (Canada) suggests five important questions to ask your doctor, nurse and pharmacist about your medications. They are:

• 1. What has changed about your prescription and why?

• 2. What medication do I need to continue taking? Why?

• 3. What is the correct way to take the medication? How long?

• 4. How do I know the medication is working? What are the side-effects?

• 5. What followup do I need?

Seniors should ask these questions every time they are prescribed a new medication, given a medication and when they buy medications without a prescription (over-the-counter medications). They should also ask questions in the hospital, at the pharmacy and with the nurse or doctor during health-care appointments.

A second way to reduce the risk of a potential mix-up is to review medications at transition points, such as when moving into a personal care home, at discharge from hospital, picking up new prescriptions from the pharmacy and when receiving home care.

Health experts say this action alone would significantly reduce the potential for harm from medication incidents. Seniors should work with their doctor, nurse or pharmacist to make sure nothing is missed and that all differences between what you are taking compared to written instructions is talked about.

The health-care system does its best to ensure the right medication information is communicated each time a patient moves from one health-care setting to another. However, when medication mix-ups occur, it is most often from miscommunication or lack of communication.

To assist seniors with both of these important actions, the Manitoba Institute of Patient Safety has created a special card that can be used to list all of your prescription and over-the-counter medications, including vitamins, minerals and herbal/natural products.

The It’s Safe to Ask medication card can be obtained by visiting

Print the card and fold it into a handy wallet size. Let family members, friends and loved ones know you have the card. Keep it up-to-date and share it with your doctor, nurse and pharmacist.

Laurie Thompson is the executive director of the Manitoba Institute for Patient Safety.

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