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The 5 Rights of Medication Administration

Dec 13, 2016

Male, 56 years of age, type 2 dm, hypertension with orthostatic hypotension, peripheral neuropathy, hyperlipidemia, class II obesity. He fills his pill box every month and has been doing so for years. It has taken some time, but we finally came up with a plan with his meds and lifestyle where he has been feeling very well and his numbers are better than ever.

He filled his med box a week before contacting me. He wasn’t feeling well. Feeling dizzy and his legs were feeling like rubber. I asked him if anything had changed in the way he was taking his medicine or anything else. He did not think so. I asked him to come in later in the day so we could check, and to bring his medications, med bottles and even his receipt for his meds. He did so.

We recognized one of his blood pressure meds that he was taking, 50mg twice a day, was filled incorrectly at the pharmacy. It was filled for 100mg twice a day. The pill itself looked the same, a tiny bit larger, but not larg enough to really notice the difference unless one puts the new and the old on top of each other. Problem solved! We contacted the pharmacy. The pharmacist looked at their records and found that true enough, the prescription had not changed, but it was filled incorrectly. The pharmacist apologized and replaced the medication with the correct dosage of the medication.

The patient did not take any of the antihypertensive the evening after seeing me, felt better the next day and resumed at his usual dose.

Disaster partly averted. Although the patient had an adverse reaction to the misfilled medication, we caught it early enough to prevent any further disasters such as a fall or having to come up with a new regimen that could take quite a while, with some disasters on the way to finding the “secret sauce.”

Lessons Learned:

Teach patients:

  • ALWAYS check the label on the bottles of medicines they take before taking them. It’s easy to get so used to what one takes, to just take the pill without checking the label.
  • If a medicine they are used to looks different, double check the label. Some generics will look different. There is usually a note on the label stating the medicine looks different, but it is the same. If there is no such label saying it is the same, call the pharmacy and explain that your pill looks different. Ask the pharmacist to check what exactly was filled.
  • Changing pharmacies can mean a change in what your medicine looks like. Double check with your pharmacist that what you received is correct.
  • Always go to the basics, which are the 5 rights of medication administration…Right person, right drug, right dose, right time, right route.


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