Nearly one-fifth (19%) of hospital RNs reported that medication error involving patients in their care had occurred "occasionally" or "frequently" in the past year. However, medication mistakes are also likely to occur in homes. Over-the-counter products give dosages and warn patients about taking more than the recommended amounts, but labels can be misread. Even with the best of intentions, medication mistakes can occur.
In my disorganization, I set the medication on the table but not in my purse where it was supposed to go. Upon our arrival the rash worsened, but only then did I realize I had left the bottle of medicine behind.
I was able to find a pharmacy a short walk from where we were. I grabbed a package from the shelf that was in the form of a liquid because my daughter has an aversion to swallowing pills. However, this time it was not a liquid meant only for children; it was called "elixir" and had dosages for children up to adult. For a teaspoon I was delighted that I had a plastic spoon in my van. Still in "maximum dose" mode, I gave my daughter four spoonfuls of the liquid.
Almost instantly her hives disappeared, but at dinner she was acting extremely tired. When my husband asked me how much medication I had given her, I said, "Four teaspoons."
He wondered what the suggested dose was, and I pointed out "2-4 teaspoons." Then he asked to see the spoon I had used. Using water from the pitcher at our restaurant table, he showed me that the capacity of this spoon was equivalent to a tablespoon, three times as much as intended.
I felt sick. How could I have done this to my child? I had read the label and yet I had made a major mistake. My sense of familiarity with an over-the-counter drug had kept me from being careful and wise.
Thankfully there were no other adverse affects on my daughter, and her hives have not returned at all.
I have no way of proving this, but I believe that God in his providence is able to hold back the full extent of the consequences of mistakes we make. Many medication mistakes at home or in hospitals may not even be noticed by God's grace, depending upon the drugs involved.
That knowledge and belief should not make me careless; however, I have a sense of deep gratitude that my daughter's story did not have a tragic ending. I have also learned to have a fresh and healthy respect for medicines, prescriptions and otherwise.