I had the opportunity last week to take a long ride with my sister-in-law (who lives in Maryland) when we traveled to a family reunion. We talked about many issues, but one keeps coming back to me as the consequences could have been deadly. Sherry, who has two young children, told me a story about a recent encounter she had with her retail pharmacy. Both children were sick last week and needed medication. On her way home from the pediatrician’s office, she dropped the prescriptions at her local retail pharmacy (a very common chain). Later that day, her husband Dan picked up the medications. Anxious to start the medication, Sherry took the bottles and began getting ready to give each child their individual medication. As part of the process, she read the bottles and found that the bottle intended for Ryan (14 months old) had a different child’s name on the bottle. After she alerted her husband, he jumped back in the car and returned to the pharmacy where he told the pharmacy aide about the problem. She took the medication back and returned with a new bottle. This time Dan checked the bottle and it did have Ryan’s name marked clearly on the label.

Once back, Sherry took the bottle and in checking, noticed that the dose was different than that which the doctor usually gave Ryan. She called the pediatrician’s office to check on the dose. After an hour’s wait, she got a call back from the office and asked them to pull the record to see what dose the doctor had ordered. The dose that the doctor ordered and the dose on the bottle were different. Again, she called the pharmacy and asked to talk to the pharmacist. After what seemed to be a long wait, the pharmacist came on the line. She asked him to pull the prescription for Ryan and check the script against what was filled by his pharmacy. There was silence on the other end. He finally said, there seems to be a mistake here . . . have you given any of this to your child??? When Sherry said no, the pharmacist said that was good as the dose was twice as high as it should have been! He asked her to bring the medication back and they would change it.

Dan went back to this pharmacy and got a third bottle of medication. This time, Sherry was able to give her child the medication. This is one example that provides a clear example of medical errors that occur day in and day out across the country. This error was caught early, corrected and no harm done. But what if Sherry did not check the name on the bottle or remember the dose that her doctor usually orders for her son? What if Sherry had not been able to take the day off and care for her two young children and had depended on the day care team to give the medication to her child? It really scares me to think of the answers to these questions.

As many of us learned when we were in nursing school, before giving any medication it is important to check the five Rs: the right person, the right drug, the right time, the right route, and the right dose . . . as you can see, this type of education is essential to share with all consumers. It is important to educate all consumers so that they have the knowledge and the tools to prevent serious medical errors for the medication they are giving to themselves, their spouses and their children.

Sherry is not a healthcare professional. She is a conscientious mother who has the education to advocate for her family to make sure they receive the correct treatment ordered by healthcare professionals. She does not leave it up to the healthcare professionals as she knows people make mistakes. Unfortunately, not all people are like Sherry, so it is up to all healthcare professionals to alert the consumers with whom they come in contact about simple procedures that they can use to protect themselves and their families proactively against healthcare errors!

As a result of the experience that I had on the drive to the family reunion, I have focused this week’s issue of Across my Desk on issues related to improving safety and quality within our system. Case managers are an important resource for those developing those systems so make sure you read each report and see where your skills would be best utilized. If you are looking for a career change or are satisfied with your current position, you will find the articles timely and useful.

Till next week, take some time to enjoy the remainder of the summer, and do what you can to keep yourself and your family healthy, safe, and happy!

Anne Llewellyn, RN-BC, MS, BHSA, CCM, CRRN
Editor-in-Chief of Across My Desk, Case in Point magazine, and the Case Management Resource Guide
allewellyn@dorlandhealth.com