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What’s in your medicine bottle? Your prescription may not be what the doctor ordered!

Consumer Reports News: April 21, 2008 12:01 PM

Just last week, two patients asked me how they could tell if they were getting the right drug. Their pharmacy benefits plan had mailed them their refills, but the drugs looked totally different. In the case of my migraine patient, Leslie, 80 milligrams of Inderal® was now a blue capsule whereas in the past it had always been a yellow tablet. "How do I know if I’m getting the right thing?" she asked.

It's a good question and consumers have a right to be concerned. Years ago when my brother developed bronchitis, he was given a script for the antibiotic Vibrax® (a drug no longer prescribed) by our family physician. By the time he had finished the bottle, his cough was worse and he was even more run down, so the doctor's office phoned in another course of treatment. It wasn't until my brother picked up the pills from the pharmacy and saw that they looked different that he discovered that he had been taking Librax®, a sedating medication, by mistake—the "V" on the original prescription had been mistaken by the pharmacist for an "L."

Thirty years later, more than three-fourths of physicians are still scribbling prescriptions and look-alike and sound-alike errors are still being made. Although digital tools such as handheld prescribing devices and electronic health records are now available, only about 20 percent of us use them, and alas, our handwriting has not improved.

The truth is we have a long way to go. While there may be more programs to increase public awareness and better safety checks, the situation is also getting trickier for savvy patients, like Leslie, who want to do their part. State laws regarding notification vary, but pharmacy benefits managers don’t necessarily contact patients or physicians when formularies are changed, and unless your doctor specifies that a brand name drug be dispensed, you will likely receive a generic drug if one is available.

When Leslie called her health plan’s mail-in pharmacy she was told that there should have been a label stating that it was indeed the same drug even though it looked different. If you find yourself in the same position, there are quite a few medication web sites and books such as the 2008 Consumer Reports Drug Reference Book that provide drug photos, drug identifiers and other important drug information tools.

To help ensure you are taking the right medication for the right condition at all times, the Agency for Healthcare Research and Quality advises:

  • Read your prescription. If you can’t read your doctor’s handwriting, your pharmacist might not be able to either.
  • Know what your medicine is used for. Ask your doctor to write what the medication is being prescribed for directly on the prescription. Ask questions!
  • Try to use the same pharmacy. Pharmacy databases can catch many errors including duplication of medications (I once had a patient come in on Ultram®, Ultracet® and generic tramadol—all three containing the same pain medication, all from different pharmacies, an error that would have been avoided with one pharmacy). A pharmacy’s computer can also check for drug-to-drug interactions and dosage errors.
  • Make sure that the medicine is what the doctor ordered. Does the label vary from the prescription or look different than what you expect? Does a refill have a different shape, color, or size than what you were given before? If anything seems wrong, ask the pharmacist to double check it.
  • List all the names of your medications, vitamins and supplements. I advise all my patients to do so. It will help coordinate your care if you have multiple doctors, and keep you safer if you need to see someone as an emergency. One of my patients showed me her trick—she jots down her meds on an index card laminated with extra wide scotch tape to make it waterproof.

Orly Avitzur, M.D., medical adviser to Consumers Union

Read more on how to avoid common medication mistakes and how to manage multiple medicines.

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