MEDICATION SAFETY
Are We Speaking
The Same Language?
M
any people, even health care professionals, have trouble functioning well
as patients. The television show, “ER,”
portrayed this problem in an episode
where a Spanish-speaking woman
misunderstood the directions for taking
INH (isoniazid). The prescription label stated to take the
medication “once” daily. But in Spanish, “once” means
“eleven.” In the show, the patient died from taking such
an excessive dose.
A similar, real-life problem occurred when a Spanishspeaking mother applied Oxistat (oxiconazole) 1 percent
cream to her baby’s inflamed rash up to 11 times each
day. The mother was simply following prescription label
directions that stated, half in English and half in Spanish,
“Aplicarse once cada dia til rash is clear.” Fortunately, no
permanent harm resulted. Had this been an oral medication, things could have been much more serious.
When a pediatric patient with seizures was discharged from the hospital, the physician wrote the
following prescription: “phenytoin suspension 30 mg/5
mL, take 5.8 cc three times a day.” Since the patient
and his family spoke only Spanish, the nurse gave the
patient’s mother the written prescription and an oral
syringe marked with tape at the 5.8 mL mark. However,
because phenytoin suspension is no longer commercially available in the 30 mg/5 mL concentration, the
pharmacy where the mother took the prescription filled
it with phenytoin 125 mg/5 mL. The prescription was
labeled correctly and stated that the patient was to be
given 1.3 mL three times a day. The pharmacist, who
did not speak Spanish, could not counsel the patient’s
mother. As a result, the mother used the syringe the
nurse had given her, and she administered 145 mg three
times a day instead of 34.8 mg three times a day. A few
days later, the patient was readmitted to the hospital ICU
unit nearly comatose with phenytoin toxicity. The child
recovered and was discharged.
14
america’s
Pharmacist | December 2008
In another example, a physician prescribed
“Amoxicillin 200 mg/5 mL” with instructions to
administer 5 mL TID for a 3-year-old child. The
pharmacy carried only a 250 mg/5 mL strength,
so the pharmacist changed the directions to
“Take 4 cc (4/5 teaspoonful) by mouth 3 times a
day.” The child’s father misunderstood the directions, as English was his second language. He
didn’t know what “cc” meant, but upon seeing
“4/5 teaspoonful,” he thought he should give his
child 4.5 teaspoons of the medication. After five
doses, he brought his child to the emergency
department with severe diarrhea. The use of two
abbreviations contributed to the error: “cc” and
a slash mark ( / ).The child’s father did not interpret either abbreviation as intended. Inadequate
patient counseling also played a role. Although
he had been given a 10 mL measuring device
for oral solutions marked in mL and teaspoons,
specific directions for measuring each dose
were not reviewed with the father when picking
up the prescription.
Safe Practice Recommendation
If you have a lot of patients who speak another
language, consider having patient information brochures already translated into that language.
This article has been provided by the Institute for Safe Medication Practices (ISMP). The reports described in this column
were received through the USP–ISMP Medication Errors Reporting Program (MERP). Errors, near misses, or hazardous
conditions may be reported on the ISMP (www.ismp.org) or
U.S. Pharmacopeia (www.usp.org) Web sites. ISMP can be
reached at 215-947-7797 or ismpinfo@ismp.org.
www.americaspharmacist.net