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Two Prescriptions But Only One Medication

Last week we had a patient new to our practice come into our office with a bag full of all her medications.

The bag contained 16 bottles from different pharmacies and she told us that the medications were for her diabetes, hypertension, and nerves. During the appointment she indicated that she often had low blood pressure, was at times very dizzy and felt like she was going to fall when she got up from her chair.

We lined up all her medications and I was getting ready to review them with her, when I saw that she had two prescriptions for lisinopril, one for 20mg and one for 40 mg, each to be taken daily.

I questioned her on this and she told me the 20mg was for her kidney and the 40mg was for her hypertension. Sure enough this was indicated on each label and had been filled at two different pharmacies.

Her former primary care physician had started her on the 20mg secondary to her long history of diabetes and a cardiologist had given her the 40mg due to her elevated systolic readings.

We had the patient discontinue the 20mg and just stay on the 40mg. The hypotensive problems resolved after this change and the patient is doing fine.

Lesson Learned:

Many times patients are given the same medication for different reasons. ACE-I’s such as lisinopril are often given to patients with diabetes who are not hypertensive.

These patients are not familiar with all the reasons we may use a medication. If we don’t explain this to the patient they will often either stop taking the medication or take two different strengths of the same medication. In addition we recommended to her and to all our patients that they fill all their prescriptions at the same pharmacy so that the pharmacist could have recognized the problem and advised us or the patient accordingly.

Susan A. Blair, ARNP

Baltimore, MD

 

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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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