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An elderly woman at an adult day-care center went to see the nurse for a routine checkup. The nurse asked if her doctor had prescribed any new drugs recently. The woman replied that she had "a lot of new pills" but couldn't remember their names. So the nurse asked her to bring them on the next visit.
A week later, the woman brought a bag filled with her current medications. After checking the labels, the nurse saw that the "new" drugs were simply generic formulations of brand name drugs the woman had already been taking. Because neither the doctor nor pharmacist had explained this to the woman, she'd been taking double doses of all her medications for over a week.
The nurse made an appointment for the woman to be examined by her doctor. She also alerted the woman's family and told them which drugs she should be taking. The doctor found the woman hadn't suffered any ill effects from the extra doses.
This potentially dangerous error could have been prevented if the doctor or pharmacist had told the woman that the "new" (generic) drugs were to replace the drugs she was already taking. Including medications with the directions would have helped. For example, For blood pressure may alert the patient if these are two drugs with the same purpose noted. Also, if permitted by law, the pharmacist could have labeled each container with both the generic and brand names.
Even if you're not a community health nurse, be alert for similar errors. During patient interviews, review the patient's drug regimen and check for duplicate prescriptions. Urge community pharmacists to put both the generic and brand names on a drug label. Finally, encourage patients to patronize pharmacists who keep patient prescription histories and review them when new prescriptions are ordered. This way, the pharmacist can alert the patient and doctor to any potential problems.