April 2005, Volume 35 Number 4 , p 10 - 10
© 2005 Lippincott Williams & Wilkins, Inc. Volume 35(4) April 2005 p 10 Hodgepodge in a bottle [MEDICATION ERRORS: HOME MEDICATIONS]
COHEN, MICHAEL R. RPH, MS, ScD
President of the Institute for Safe Medication Practices
When an 82-year-old patient was admitted to the hospital for treatment of unstable angina, her health care practitioner ordered that she be allowed to use her medications from home after a pharmacist inspected them.
The patient was supposed to be taking the angiotensin-converting enzyme inhibitor lisinopril, 5 mg, twice a day, but her prescription bottle was labeled “10 mg tablets.” When the pharmacist inspected the tablets, she noticed that all weren't quite the same color. The bottle also contained both whole and half tablets. Because of these discrepancies, the pharmacist didn't approve the medication for administration ...