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Danger of Prescription Drug Mix-Ups

doctorSaturday morning I was in one of our local pharmacies and overheard a conversation between the store manager and a very angry woman with an elderly man.  Essentially, the pharmacist had put the wrong medication in the pill bottle.  For three days this man had been taking pills for a urinary tract infection (UTI) instead of his appropriate prescription (my eavesdropping skills are not very keen so I was unable to hear what his ailment was or what medication he was suppose to receive). But the bottom line was he was given the wrong pills and the lady was “willing to bet a dollar” someone out there was not taking the right pills for a UTI and was instead taking his.

As a mom, this really got me wondering, and worrying, how often this happens?  And what if the mix up was with a child, with a powerful drug?  Just recently a friend of mine’s teenage daughter asked a group of girls if they had an Advil since she had a headache. A girl she knew gave her two blue pills and told her they were Advil – they were not – it was Xanax.  Luckily my friend’s daughter called her mom telling her what happened and that she felt “weird.”  This is just another example of how easy it is for our kids to come in contact with dangerous drugs.

I remember telling my kids when they were in just 1st and 2nd grade and started going on play-dates without me to never, ever take any kind of pills at a friend’s house.  Most homes have some type of prescription drugs in the medicine cabinet.  It seems logical to me that kids today would have much easier access to prescription drugs than street drugs… and that is in fact the case.

Last April a study was released by The Partnership at and the MetLife Foundation that confirmed one in four teens has misused or abused a prescription drug at least once – a 33% increase over the past five years.  One in eight teens (13%) confirms they have taken stimulants Ritalin or Adderall when it was not prescribed to them. This doesn’t count all the teens (and adults) abusing these two drugs when it is prescribed.  Even more concerning is that 23% of teens say their parents don’t care as much about misusing prescription drugs compared to illegal drugs and that of those kids who say they have abused Rx medications, one in five (20%) did so before the age of 14! And it’s not surprising then that a quarter of teens in the survey found that misusing and abusing prescription drugs are safer than using street drugs.

But back to the situation at the pharmacy with the lady and the elderly man who received the wrong pills.  Let’s assume our children are not sneaking into parents medicine cabinets and stealing pills (they are) what are the chances of our kids receiving a harmful drug by mistake at the pharmacy. How does this happen?

Sometimes it’s due to a doctor’s messy handwriting, sometimes the wrong pills are put in the wrong bottle…. It’s all human error. It’s important to really look at your prescription and what is written on the Rx bottle you pick up. Unfortunately many drugs have similar-sounding prescription names or look-alike drug product packaging.  For example, Adderall and Inderal – Adderall is a stimulant used to treat Attention Deficit Hyperactivity Disorder; Inderal is used to treat high blood pressure.  Or Amaryl and Reminyl – Amaryl is an anti-diabetic treatment; Reminyl is an Alzheimer’s medication Celexa and Celebrex – Celexa is an antidepressant; Celebrex is a painkiller. Lodine and Codeine – Lodine is used to treat mild pain and decrease swelling; Codeine is used to treat moderate to severe pain. Flonase and Flomax – Flonase is a nasal spray; Flomax is a prostate drug.  The list goes on and on…. And as a mom it makes me very nervous.

So what can we do to make sure a prescription drug mix up doesn’t happen to our kids or other family members?

According to the Mayo Clinic communication is the key.  If you don’t understand something your doctor says, ask for an explanation. Whenever you start a new medication, make sure you know the answers to the following:

  • What is the brand or generic name of the medication?
  • What is it supposed to do? How long will it be until I see results?
  • What is the dose? How long should I take it?
  • Are there any foods, drinks, other medications or activities I should avoid while taking this medicine?
  • What are the possible side effects? What should I do if they occur?
  • What should I do if I miss a dose?
  • What should I do if I accidentally take more than the recommended dose?
  • Will this new medication interfere with my other medication(s) and how?

When you pick up the prescription from the pharmacists ask some of these same questions and make sure the answers match. If they don’t – speak up. Have the pharmacist double check the prescription or even call the doctor.

The Mayo Clinic also has these tips for  playing it safe with medication:

  • Keep an up-to-date list of all your medications, including nonprescription and herbal products.
  • Store medications in their original labeled containers.
  • Save the information sheets that come with your medications.
  • Use the same pharmacy, if possible, for all of your prescriptions.
  • When you pick up a prescription, check that it’s the one your doctor ordered.
  • Don’t give your prescription medication to someone else and don’t take someone else’s.

The Mayo Clinic also warns: “Don’t ask, don’t tell” is never a smart policy when it comes to medications and your health. Don’t hesitate to ask questions or to tell your health care providers if anything seems amiss. Remember, you’re the final line of defense against medication errors.

If despite your efforts you have problems with a medication, talk with your doctor or pharmacist about whether to report it to MedWatch — the Food and Drug Administration safety and adverse event reporting program. Reporting to MedWatch is easy, confidential and secure — and it can help save others from being harmed by medication errors.

It’s up to us moms (and dads) to be advocates for our children when it comes to their health. So often we don’t want to seem rude and so we don’t ask the questions we should. It is better to offend someone if you think they have made an error, than to risk giving your child the wrong medication.

Likewise, it is up to us to talk to our kids, at a very young age, what pills are. And to tell them to never, ever take pills from anyone or at anyone’s house. The only person that a child should take any pill from is their parents or guardian or school nurse.  Just like with everything these days, it’s sad that you can’t trust everyone. But the bottom line is… you can’t.

From one mom to another,

Jenny Wilson

Young Title Company