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The Pill Holder Error

Apr 2, 2012
During an office visit with one of my 68 y/o white female patients, she was complaining of constant thirst and excessive urination. She also expressed concern that she felt tired all the time. I looked at the chart and found the patient was taking….

HCTZ 25 qd Metformin 500 bid
Lisinopril 20 qd Naproxen 500 q8h
Simvastation 20 qd Alprazolam 0.5 tid
KCL10 qd Zolpidem 15 qhs

My first thought was that she needed an increase of metformin due to high glucose levels but an after-lunch check showed a glucose reading of 135 mg/dl and her last A1c was 6.6. I asked her about taking her medicine and she pulled a large daily dose pill holder from her purse and showed me that she separated her medicine into times that she took them. She was adamant that she was taking them exactly as they were prescribed.

When I looked in the pill holder I saw that some days there were oval tablets in each of the three daily slots and on some days there were round ones. When I asked the patient she told me that the last time she got her Alprazolam the shape of the tablets were now round.

I had one of my MA’s call the pharmacy and they identified the new round tablet as HCTZ 25mg. This meant that the patient was taking her diuretic 3 times a day and explained the reason for her complaints.

It appears that my patient had spilled her medications on the counter and when she put them in her pill holder she inadvertently loaded HCTZ rather than Alprazolam in each of the three daily slots.

Lesson Learned:

Often times to make medication dosing easier for patients, caregivers and other family members will place medications in a pill holder separated by times of day. This works well for many patients but as time goes by the responsibility for filling these holders at times will revert back to the patient from time to time opening up the chance for error. In addition pharmacies often change generic suppliers and the shape of color can be different.

It would be wise for all patients who use these holders to have a list of their medications with a description so they can avoid placing the wrong tablet or capsule in the time slot and this list should be checked and updated every time they refill a prescription.

Raymond Raitz, MD

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