I’ve seen numerous errors where the patient thought something was a little off and said something to a healthcare professional. One of the most important medication safety tools in healthcare is listening to the patient. Patients will sometimes say things that seem insignificant, but certain comments should immediately trigger a pause before you administer or dispense a medication. These “alarm bells” can catch prescribing, dispensing, labeling, and administration errors before they reach the patient. I wanted to share some examples of statements from patients that should make you pause and recheck to see if we are making a medication error. If you are looking for more on medication errors, be sure to check out my podcast episodes.
“I’ve never taken this medication before.” This should prompt you to verify the indication, dose, directions, and intended medication. New medications are common, but if the patient was expecting a refill of a chronic medication, this statement becomes much more concerning. Compare the new prescription with the medication history and the patient’s previous therapy.
“That pill looks different than what I usually get.” Don’t automatically assume the patient is mistaken. Manufacturers, colors, shapes, and imprints can change, but a different appearance can also indicate a dispensing error. Stop and verify the drug, strength, manufacturer, and NDC when appropriate.
“My doctor told me to take one, but the bottle says two.” This is a major red flag. There may be a legitimate dose change, but there could also be a transcription, prescribing, dispensing, or labeling error. Clarify the discrepancy before the patient takes the medication.
“I thought this was supposed to be my blood pressure medicine.” Patients don’t always know the names of their medications, but they often know what the medications are supposed to do. If the medication in front of you doesn’t match the patient’s understanding of its purpose, investigate rather than simply assuming the patient is confused.
“I usually take this at night.” This can uncover administration errors involving timing. Some medications have important administration considerations involving meals, bedtime, morning dosing, or separation from other medications. A patient’s established routine can provide an important clue that something has changed.
“I’m supposed to cut this pill in half.” This should make you look carefully at the dosage form. Extended-release, delayed-release, enteric-coated, and certain other formulations should not routinely be split. The patient may have been instructed to split a different strength or formulation.
“The pharmacist usually gives me a different number of pills.” Quantity discrepancies can be another warning sign. A smaller quantity could be intentional, but it could also reflect a partial fill, an incorrect day supply, or a dispensing mistake.
“I’m allergic to that.” Take this seriously. Even if the allergy isn’t documented, don’t simply dismiss the patient’s statement because the medication appears to be commonly tolerated. Clarify what happened with the previous exposure and verify the allergy information.
“The doctor said I could take this when I needed it.” Be careful with PRN medications. The patient may have misunderstood the frequency, indication, maximum daily dose, or duration. PRN instructions are particularly vulnerable to communication and transcription errors.
“I stopped taking that because it made me sick.” This can reveal that the medication being dispensed is not what the patient expected, or that an important adverse-effect history has been overlooked. It may also uncover duplicate therapy when the patient has already discontinued one medication but receives another medication in the same class.
“I only take one of these every other day.” If the prescription label says daily, don’t simply tell the patient to follow the label. Investigate why the patient has been using a different schedule. The patient may have received previous instructions from another clinician, or the current directions may be incorrect.
“This is the liquid I give my child, but the amount looks different.” Liquid medications deserve extra scrutiny because concentration errors can create major dosing problems. A patient or caregiver noticing a different volume, concentration, syringe, or bottle can provide an important clue to a medication error. Liquid meds can be confusing. I recently blogged about oral liquid morphine and life-threatening medication errors.
“I was told not to take this with my other medication.” This should trigger an interaction check and a review of the patient’s complete medication regimen. The patient’s statement may be based on something a previous clinician told them, an interaction they experienced, or a misunderstanding. Either way, it deserves clarification.
“I don’t recognize this name.” Brand and generic names can create confusion, but this comment should still prompt verification. Patients may recognize a medication by a completely different name than the one appearing on the label.
“I don’t think I’m supposed to take this anymore.” This is one of the most valuable things a patient can say. Medication lists frequently contain discontinued medications that remain active in electronic systems. Before handing the medication to the patient, determine whether the therapy was actually discontinued and whether a newer prescription replaced it.
The big takeaway is simple: patients frequently provide the final safety check in the medication-use process. Comments about a medication looking different, a dose being different, a quantity being different, an unfamiliar medication, a different route, or instructions that don’t match what they were told should never be brushed off. A five-minute conversation can prevent a medication error that otherwise might not be discovered until after administration.
When a patient’s words don’t match the prescription, label, medication administration record, or expected therapy, stop and investigate. “That doesn’t sound right” is sometimes the most important medication safety signal you’ll hear all day.
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