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A community health nurse visited a patient who'd just been discharged after having vascular surgery. The patient told her he was doing fine, but he didn't know how he was expected to swallow the two large capsules his doctor said he should take four times a day. He'd been able to get down only one.
The nurse asked to see the bottle containing these capsules. When she saw the label, she wasn't surprised the patient couldn't swallow them. The medication in the bottle was Neutra-Phos, a powdered phosphorus supplement packaged in capsules. The powder is meant to be emptied from the capsules and dissolved in a glass of water. But the label instructions said simply: "Take two capsules four times a day."
Apparently, the patient wasn't told how to take his medication. He was lucky he couldn't swallow more than one capsule because doing so could have caused severe gastric upset. The nurse showed him how to dissolve the powder, then called his doctor and pharmacist to tell them what had happened.
You can prevent such errors by encouraging doctors to write explicit administration directions on each prescription order, and encouraging pharmacists to type those directions on the drug label. Make sure the patient has received and understands the directions before he leaves your care.