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Diabetes Disaster Averted #69: Take as Directed!

Feb 6, 2012

A patient was given a prescription for glipizide twice a day "as directed (ut dict)"….

When the patient came into the pharmacy for a refill, he commented that he really disliked getting up at 2AM to take his medication. The pharmacist then called to verify that the patient was to take his glipizide twice a day at 2AM and 1PM, as the patient stated. After calling the doctor’s office to confirm the unusual directions, the pharmacist discovered that the doctor told the patient to take it twice a day, morning and evening. Somehow the patient misunderstood what the doctor had said. The patient was very glad to be able to sleep through the night.

Lesson Learned:

Prescriptions should never be written with the directions, "Take As Directed."

When writing a prescription, the directions should be spelled out and reviewed with the patient before leaving the office to prevent possible misunderstandings. To prevent these types of errors, every prescription should be written with the exact directions and the person dispensing the prescription at the pharmacy should always ask the patient, "How did your doctor tell you to take your medicine?"


Report Medication Errors to ISMP:

Diabetes in Control is partnered with the Institute for Safe Medication Practices (ISMP) to help ensure errors and near-miss events get reported and shared with millions of health care practitioners. The ISMP is a Patient Safety Organization obligated by law to maintain the anonymity of anyone involved, as well as omitting or changing contextual details for that purpose. Help save lives and protect patients and colleagues by confidentially reporting errors to the ISMP.



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