An older adult male was found unconscious in his bedroom with several different white pills besides his bed, but no labeled pill bottle can be found. He is rushed to the emergency department for treatment.
The most helpful drug reference source in this situation
In the described situation, it is best to use Prescriber’s Digital Reference (PDR), formerly known as Physicians’ Desk Reference. Previously, the book, and at the moment, the website provides prescribing information (package insert) about medicines that can be prescribed to patients. In addition to detailed information, the advantages of this tool are that it is convenient and accessible, and its application also has an unlabeled pills recognition capacity (Presenter’s Digital Reference). The latter function is indispensable in the studied case since no labeled pill bottle can be found.
The difference between these two medication orders: A. Give two Tylenol, PO; B. Give one Tylenol No. 2 PO
These medical orders have several differences key to treating patients. PO in both cases means ‘per os’ – from Latin ‘by mouth,’ – take pills orally (Sekhon). In case A, it is necessary to give the patient two Tylenol tablets, which contain only acetaminophen (“Tylenol”). In case B, one tablet of Tylenol No. 2 contains acetaminophen and codeine (“How to use Tylenol-Codeine # 2 Tablet”). Thus, the medications and the number of pills taken differ.
When and why Tall Man Lettering should be used
Tall man lettering is a way to secure patients’ medication and prevent confusion using capital letters in drugs’ names. Examples of using the method are as follows HYDROcodone and oxyCODONE, traMADol and traZODone. This method helps patients distinguish similar medicines or drugs with similar names, and studies have proven its effectiveness (Larmené-Beld et al. 986). Safety in medication is critical as improper measures can worsen a patient’s condition.
Patient education that can be done to prevent medication confusion incident from happening in the future
The primary measure that medical staff can take to prevent confusion with drugs is detailed counseling of the patient before they are taken. Patients may misinterpret or fail to understand the written instructions. During counseling, if a person has not yet taken prescription medication, the doctor can show them to the patient indicating the distinguishing features and emphasizing the importance of proper administration. Another valuable piece of advice can be given on how to store drugs so that labels were visible.
Larmené-Beld, Karin HM, et al. “A Systematic Literature Review On Strategies to Avoid Look-Alike Errors of Labels.” European journal of clinical pharmacology, vol. 74, no. 8, 2018, pp. 985-993.
Prescriber’s Digital Reference (PDR). PDR, LLC, 2021. Web.
Sekhon, Lali. “Understanding Your Prescription.” Spine Universe. 2018. Web.
“Tylenol.” RxList. 2021. Web.
“Tylenol-Codeine #2 Tablet.” WebMD. Web.