Medication Mistakes can be Stepping Stones to Better Care

Ever made a mistake? I have. I will never forget that feeling – it’s awful.

I was reviewing a patient’s medication list and noted that the patient was struggling with the costs of their medications. I was a fairly recent new graduate at the time and the patient was taking Lipitor (brand name) at the time at a dose of 10 mg. I suggested that we change it to Zocor (simvastatin) 20 mg which was generic and much cheaper – a recommendation I had certainly made before. What I failed to realize was that this patient had an intolerance to simvastatin that was on their allergy list. (By the way, this is why we have multiple checks in place to prevent one person’s mistake from getting to the patient) I flat out missed it. I remember coming across it at a later date (which I’m very thankful to be able to learn from this without patient harm), and found that a wonderful nurse had caught my error and prevented a negative outcome. When I went to thank her for catching the error and saving me, she was totally oblivious and could hardly even remember it. Medication errors happen because we are imperfect people trying to serve our patients perfectly. I tell you this story, because it’s real, and it happens. We all must learn from our own mistakes, as well as the mistakes of others to continuously improve the quality and safety of our care. Paraphrasing Vince Lombardi, “Relentlessly pursue perfection, and along the way you’ll catch excellence” To the nurse who I’m sure doesn’t remember this story by now – Thank you. We really are all in this together.

Thanks for reading!  I’m giving away a 6 page PDF on 30 medication mistakes I see in my practice, please take advantage of the free and unique opportunity!


  1. Fran Husson

    What an excellent and candid post, which leads me to ask a question: was the patient involved in the prescribing?? Unless patients suffer from cognitive impairments, there is no reason why the choice of medication, the changes in dosage, frequency and provenance could not shared. Patients too often [and I know because I am one!] passive and…lazy, relying entirely on others to help improve their health and wellbeing. Patient activation is one sure way to reduce the number of medication errors across care settings.

    • chri1599

      Excellent point! This was in a nursing home, but the able/willing patient/caregiver can be the last (or first) line of critical defense in preventing mistakes!

  2. Ed Meinardus, Pharm.D. .

    Maybe I’m stupid, but the incident raises lot’s of questions that are still valid today (possibly even more so in light of new “statin” recommendations. 1) Was the request for “Lipitor” because of a true intrinsic “allergy” to simvastatin or merely an attempt to get a non-formulary
    drug covered through insurance? 2) If taking the “allergic” reaction at face value, what sort of
    allergic reaction? Mild pain not to be confused with rhadomyolitis. 3) If true “statin” allergy
    why go to atorvastatin? 4) Why “knee-jerk” reaction without at least some more information?

    • chri1599

      Excellent questions – The fact that you are asking those questions means you’re not stupid, in fact you’re the exact opposite- you’re are thinking critically. This case was a long time ago, and many of the details escape me, but the scenario is one I see slip through all lines of healthcare defense from time to time and is intended to educate on the importance of FIRST checking/assessing allergies PRIOR to asking for/initiating/or taking a medication!

  3. Luka Tehovnik

    That’s why a multidisciplinary team is of such importance! Pharmacists, doctors and nurses should cooperate and work together, we are all healthcare professionals after all! Thanks to that nurse, no error was actually made (from the patient’s perspective). However, the nurse could really gave you a hard time just because of it. We all are human, we do make mistakes but most importantly, we learn from them.


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Written By Eric Christianson

April 23, 2014

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