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Fellow Medical Toxicology Bellevue Hospital Center and New York University Medical Center New York City Poison Control Center 455 First Avenue, Room 123 New York, New York 10016-9102 fax 212/447-8223 jessicafulton{at}yahoo.com
Director Medical Toxicology Fellowship Program Associate Director New York City Poison Control Center Attending Physician Department of Emergency Medicine Bellevue Hospital Center and New York University Medical Center Assistant Professor of Clinical Surgery/Emergency Medicine New York University School of Medicine
Published Online, January 11, 2005. www.theannals.com, DOI 10.1345/aph.1E458
A national adult literacy survey reported that 40 million Americans are considered illiterate,3 and the 2000 census reported that 45 million Americans speak a language other than English at home.4 Some pharmacies have attempted to overcome the latter concern by providing education on prescribed medications and medication labeling in the patient's native language. Although seemingly useful, this is not a requirement by any state board of pharmacy.
We describe 2 pharmacy dispensing labeling errors, in which adverse events may have been prevented by removing the language barrier from the medication error equation.
Case 1. A 30-day-old Hispanic girl with non–English-speaking parents and a history of anoxic brain injury and seizures presented with lethargy and decreased appetite. She had been discharged from the neonatal intensive care unit 5 days prior with a prescription for phenobarbital elixir 20 mg/5 mL twice daily that was filled by the outpatient hospital pharmacy. In the emergency department (ED), it was discovered that a bottle of Tylenol #2 (acetaminophen 120 mg plus codeine 12 mg/5 mL) had been relabeled by the pharmacy as phenobarbital 20 mg/5 mL (Figure 1A). The infant's serum acetaminophen concentration was 2.7 µg/mL (therapeutic range 10–30), urine tested positive for opiates, and serum phenobarbital concentration was negative. She recovered with conservative therapy.
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Case 2. A 37-year-old non–English-speaking South Asian man with a history of asthma treated with albuterol presented to the ED with a severe exacerbation. Following several nebulized albuterol treatments and oral prednisone, his symptoms resolved completely. Concerns for the recurrence of such a severe attack while on appropriate outpatient therapy prompted the physician to ask the patient to demonstrate the method by which he used his albuterol inhaler. The patient removed from his pocket a box containing a tube of hydrocortisone 1% cream and applied it to the inside of his nostrils. Further inspection of the box revealed that it had a label affixed to it by the outpatient hospital pharmacy that read "albuterol" with directions to use "two puffs every 6 hours as needed" (Figure 1B).
Discussion. Recognition of errors provides an opportunity for health-care professionals to improve our systems of delivering care. In both cases, errors were made in 2 of the steps identified by the Institute for Safe Medication Practices: medication labeling and patient education.5 Had the involved parties been able to read the medication labels and thereby note that the pharmacy-affixed label and the manufacturer label described 2 different medications, the outcome of these errors may have been prevented by the end users—the patients. The addition of computerized translation programs in all pharmacies to provide multilingual prescription labeling and drug information may allow patients to become more effective participants in the prevention of medication errors.
References
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