Kensington Pharmacy



Institute for Safe Medication Practices

ISMP Medication Safety Alert


A close call involving a prescription for an over-the-the counter product, filled at a health food store, underscores the need for clear interpretation and advice on all prescriptions. Here's the story.

An elderly woman who was experiencing a variety of infections had been treated with antibiotics over several months. Because of the antibiotic use, she began to suffer from diarrhea. Her doctor told her to eat yogurt for 10 days to stop the diarrhea. However, the woman disliked the taste of yogurt and stopped after only a few days.

She again visited her doctor about the continuing diarrhea. He substituted a prescription for Lactinex® (lactobacillus acidophilus and lactobacillus bulgaricus) and told her she could get the over-the-counter product at a health food store, since it was not a prescription-only product.

The woman, who was nearly blind, gave the prescription to the clerk in the health food store to read and fill. Instead of "1 capsule, 4 times a day," the health store clerk misread the prescription as "7 tablets, 4 times a day" - nearly double the label's maximum dose. At the woman's request, the clerk clearly rewrote what he believed to be the doctor's instructions, directing her to take a whopping 28 tablets a day instead of the appropriate four tablets per day. After only one day of this larger dosage, the woman began suffering severe nausea and her diarrhea grew much worse than it had been.

Fortunately, the woman's son was a pharmacist and discovered the clerk's error in interpreting the physician's poor penmanship. The patient was then treated with fluids and appropriate medication to recover completely. Yet such incidents remind us that use of all medication, whether over-the-counter or prescription, can have unintended and sometimes dangerous outcomes. Therefore, all medication must be interpreted and used very carefully.

Visiting a qualified pharmacist for advice on any medication use can be an important safeguard. Pharmacists further the work of your physician and other members of the health care team by using their highly specialized education and experience to recognize and guard against potential medication mishaps.

Further, patients and their families can be an important safeguard in medication use by making sure that they clearly understand the doctor's medication orders before having the prescription filled. While still in the doctor's office, the patient or caregiver should write out and repeat for accuracy the new medication and dose. This new medication should be added to a full and up-to-date list that the patient keeps of all drugs he or she may be taking.

© 2007 Institute for Safe Medication Practices. All rights reserved