Medication Safety Sleuths
Facilitator’s Guide
Introduction
Create a mobile medicine cabinet to address common medication safety principles and
incorrect storage conditions for prescription and over-thecounter (OTC) medications. To conduct the activity, the
facilitator will fill a medicine cabinet with fake prescription and
OTC medications (see Tables 1 and 2) containing a medication
storage error or illustrating a medication safety principle.
Participants will read clue cards and match the answer of the clue
card to one of the medications. Below you will find the materials
and instructions needed to build your own medicine cabinet and
conduct this activity.
Materials per medicine cabinet (*see Table 1 and Table 2 for details)
1 Medicine Cabinet
1 set of printed clue cards (included on pgs. 7-11 of this handout)
1 set of printed prescription labels (included on p.12 of this handout)
1 teaspoon
1 plastic, self-sealing bag
1 “REFRIGERATE” Label*
Prescription bottles*
Variety of OTC medications*
Notes:
 Ask a local pharmacist to loan you the prescription bottles and “REFRIGERATE” label.
 Feel free to create different clues to better express additional safe medication
storage conditions or safe medication-taking practices.
 We suggest creating large, uniformed expiration labels to place on all medications in
order to help participants easily find this information.
 You may include 3-4 additional medications to demonstrate safe storage conditions
or safe medication-taking principles.
 There is an optional clue card covering storage of controlled substances. You may
wish to include this medication and clue for appropriate audiences.
1
Table 1: Itemized prescription bottle and OTC medication materials needed
Photo of
Materials
Medication
 1 prescription bottle labeled with “Prescription Label #1”

2 different OTC medications

2 different OTC cough syrup bottles


1 teaspoon
1 bottle of OTC gummy vitamins for children

1 bottle of OTC vitamin tablets for children

1 bottle of OTC eye drops

1 liquid prescription bottle labeled with “Prescription
Label #2” and a “REFRIGERATE” label

1 OTC bottle of St. John’s Wort

2-3 boxed OTC medications where the medication is
stored in foil packets


1 plastic bag
1 tube of an OTC medication

1 old expiration label

1 prescription bottle with “Prescription Label #3”

1 OTC medication


Optional:
1 prescription bottle with “Prescription Label #4”

1 OTC medication
2
Instructions
1. Following Tables 1 and 2, create and fill the medicine cabinet. To make the activity
more challenging, feel free to purchase additional OTC medications to completely fill
the cabinet and showcase examples of safe medication storage conditions.
2. Print and cut clue cards (see pgs.7-11).
3. Provide the clue cards to the participant. Introduce the activity:
 “We need some help! Our medicine cabinet is filled with different types of
prescription and OTC medications. While some medicines are stored correctly, 9
medicines are stored incorrectly. Your job is to read each clue and match it to
the medicine stored incorrectly. We’ll keep track of how many correct matches
you make!”
4. Allow participants to begin conducting the activity. Once a match is made, the
participant can remove that medicine from the cabinet and lay it next to the clue.
5. Once all matches are made, review the participant’s answers. Use the “Medication
Safety Talking Points” listed in Table 2 to reinforce why that medication was stored
incorrectly.
6. Encourage the participants to apply the medication safety principles they’ve learned
to their own medicine cabinets at home.
3
Table 2: Clue and Answer matches with accompanying talking points
Clue
Photo of answer/
medication with error
How do I re-create this
medication error?
Medication Safety
Talking Point
For your safety, medicine bottles
should only have one type of pill.
Can you find the bottle with a
combination that could make you ill?
Fill a fake prescription bottle Two medicines in the same
with two different kinds of
bottle could result in taking the
OTC pills that look differently. wrong medication or taking one
of the medications incorrectly.
Label this bottle with
“Prescription Label #1”.
When we take medicine, we
measure just so! But exactly how
much is measured, don’t we really
need to know?
Attach a common teaspoon
to an OTC cough syrup bottle
with a rubber band. For
reference, have a second OTC
cough syrup bottle with a
proper measuring cup.
Medicines aren’t candy, even if
they’re sweet and gummy. Do you
see any medicines that kids might
think look yummy?
Our eyes are a little picky, they need
their medicine very clean. So can
you spy, with your picky eye, a
medicine it will whish it hadn’t seen?
Measuring liquid medicines
using a teaspoon could result in
taking too little or too much
medicine.
Include a bottle of OTC
gummy vitamins. For
reference, you could also
include a bottle of vitamin
tablets for children.
Children might confuse gummy
vitamins with gummy bears—
inform children that these two
products are different, and they
should always consult an adult
before eating candy or taking
medicine.
Include a bottle of eye drops.
Remove the cap and dirty the
tip.
Always keep medication bottles
clean to ensure they continue to
help, not hurt, you.
4
Clue
In the fridge, the temperature is low
and well-controlled. Do you think
that we should keep some medicines
cold?
Photo of answer/
medication with error
How do I re-create this
medication error?
Medication Safety
Talking Point
Include a prescription bottle
for liquids. Partly fill the
bottle with water and include
a “REFRIGERATE” label on it.
Medications that require
refrigeration should always be
kept in the refrigerator to
prevent spoilage and to prevent
a reduction in the medication’s
effectiveness.
Label this bottle with
“Prescription Label #2”.
Some medicines can interact, they
may be dangerous in combinations.
Do you think a pharmacist should
also check our herbal medications?
Include a bottle of St. John’s
Wort.
Medications come with labels that
tell us who, when, how, and why.
Do you see any medicines without
these facts nearby?
Purchase 2-3 boxed OTC
medications where the
medicine is stored in foil
packets. Remove 1 foil
packet from each medicine
and store it in a plastic bag.
If we keep our food too long, it may
grow yucky mold. But do you know
what happens when a medicine gets
too old?
Include a tube of an OTC
medication. Modify the tube
so that it appears aged and
discolored. Tape over the
current expiration date with
a label listing an old
expiration date.
Herbal medications interact with
many prescription and OTC
medications. Always inform
your pharmacist of any herbal
medications you are taking.
Without a proper label, the
patient cannot follow
instructions. Always keep your
medication in their original
container.
Expired medications are likely
ineffective and may hurt, not
help, you. Always properly
dispose expired medications.
5
Clue
To be safe with medication, we
should follow directions directly.
Should Sandra have any pills leftover
if she used her medicine correctly?
Photo of answer/
medication with error
How do I re-create this
medication error?
Fill a fake prescription bottle
with 1 OTC medication.
Label this bottle with
“Prescription Label #3”.
Medication Safety
Talking Point
With antibiotics, if the patient
does not take the full amount
for the prescribed number of
days, the bacteria can become
resistant and become much
more difficult to eliminate.
OPTIONAL Clue Card:
“Controlled” prescriptions have
special rules that we must obey.
Can you find the medication that
should be locked away?
Fill a fake prescription bottle
with 1 OTC medication.
Label this bottle with
“Prescription Label #4”.
Clinicians encourage any
controlled substances to be
locked in a medicine cabinet or
other safe storage place.
6
Clue Cards
Print 1 set of clue cards for each medicine cabinet. If you plan to conduct this activity often,
you may consider matting and laminating these clue cards.
For your safety, medicine bottles
should only have one type of pill.
Can you find the bottle with a combination that
could make you ill?
When we take a medicine,
we measure it just so!
But exactly how much is measured –
don’t we really need to know?!
7
Medicines aren’t candy,
even if they’re sweet and gummy.
Do you see any medicines
that kids might think look yummy?
Our eyes are a little picky –
they need their medicine very clean.
So can you spy, with your picky eye, a
medicine it will wish it had not seen?
8
In the fridge, the temperature
is low and well-controlled.
Do you think that we should
keep some medications cold?
Some medicines can interact- they may be
dangerous in combinations.
9
Do you think a pharmacist should also
check our herbal medications?
Medications come with labels that tell
us who, when, how and why.
Do you see any medicines
without these facts nearby?
If we keep our food too long,
it may grow yucky mold.
But do you know what happens
10
when a medicine gets too old?
To be safe with medication, we should
follow directions directly.
Should Sandra have any pills leftover
if she used her medicine correctly?
Optional Clue Card:
“Controlled” prescriptions have special
rules that we must obey.
11
Can you find the medication
that should be locked away?
Prescription Labels
Print one set of prescription labels per medicine cabinet. Consult Tables 1 and 2 to determine
which label accompanies which prescription bottle. Tape labels directly to the bottle.
“Prescription Label #1”
“Prescription Label #2”
“Prescription Label #3”
“Prescription Label #4” (optional)
12
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