Mother Mistakes Ambien for Thyroid Medication

FDA reports 95,000 medication mistakes each year, many by patients themselves.

May 18, 2010, 5:27 PM

May 19, 2010— -- Nancy Kruger Cohen -- the harried mother of a 5-year-old and an 8-year-old -- begins each day with her gray thyroid tablet, taken on an empty stomach.

But one day, while multi-tasking under pressure -- preparing waffles for breakfast, packing lunchboxes with sandwiches and zipping up winter jackets for the walk to school -- she grabs the wrong prescription bottle.

"As the pill goes in, my tongue pauses -- Is it usually pink? -- but I swallow anyway. And then the mistake is clear," said the New York City writer and art director. "I have taken a sleeping pill at 8:15 a.m."

"The scene freezes: me, staring at the word Ambien, yelling to the girls about boots, running in slow motion to the bathroom," she said. "I used to be able to make myself throw up, but now not even a toothbrush will work, so I give up and unlock the door to find the girls, boots on. We leave."

So begins her day -- one in which she texts her girlfriends, throws up over tea, crashes in bed and eventually spends the evening playing with her children, uncharacteristically oblivious to the mess and confusion. Her memory of the day is, of course, spotty.

Since 2000, the Food and Drug Administration (FDA) has received more than 95,000 reports of medication errors -- some of them doctor or pharmacy mistakes, but many by consumers themselves.

"Chaos at home is a common denominator in a lot of accidental poisonings," said Marcel J. Casavant, a toxicologist and medical director of the Central Ohio Poison Center at Nationwide Children's Hospital in Columbus.

"Kids may be playing, mom is fixing dinner, dad is getting in from work and grabbing mail or whatever dads do," he said. "But there's a lot going on, and someone decides it's time to administer medication."

At least half of all Americans take at least one prescription drug, with one in six taking three or more medications. The biggest increases in prescriptions were for antidepressants, nonsteriodal anti-inflammatory drugs, and blood sugar and cholesterol lowering drugs, according to a 2004 Department of Health and Human Services report.

Cohen credits a grandmother who is a doctor for the array of sleeping aids in her medicine cabinet: two kinds of Ambien, as well as melatonin, progesterone cream, 5-Hydroxytryptophan and Valium, "for emergencies."

"Everyone's cabinet is unhinging with confusing chemical choices," she writes in a recent essay, "Mothers Little Helper," in the New York Times magazine.

"What happens if you take his Lipitor and he takes her Prozac and she takes their Skelaxin and they take our codeine? Or Desitin becomes toothpaste and mouthwash gets in the neti pot? We're all one misdose away from something."

Casavant said his poison control center, one of three in Ohio, fields at least 100 calls a day, "a couple of dozen" of which are unintentional medication mix-ups. "We have a lot more chemicals and a lot more medicine these days."

A school nurse recently called the poison control center because a teenager thought he might have taken his grandmother's medicine.

"It's not just a mom trying to medicate herself," Casavant said. "Sometimes we have three or four generations of people in the house, with one or more people per generation on various meds. Maybe it's not Mom taking her nighttime med in the morning, but Mom giving one of Grandpa's meds to the girl who's running late on her way to school."

Husband Takes Ambien Instead of Cialus

Stories -- some perhaps apocryphal -- abound on the Internet: A husband on a romantic holiday with his wife takes a pill from his Cialis bottle to enhance his sexual performance, but ends up falling asleep early. His wife had packed her Ambien CR in an old container.

One 50-year-old El Dorado Hills, California, woman with a clean record confesses to a driving under the influence charge after taking the wrong medicine.

"I hit an electrical pole and have sporadic recollection of events from accident to arriving at jail," she writes. "Later I discovered I had mistakenly taken Ambien instead of Zoloft [an antidepressant] at 7 am that morning. Medications are identical color and shape, but differ slightly in size. I am really shook up."

Others confuse eye drops with ear drops; allergy medicine with beta blockers. One woman said she inadvertently brushed her teeth with Preparation H.

And it's not just medications that are a problem. Myszka Watt of Worcester, Mass., left her house in a rush, grabbing what she thought was hairspray and doused her hair with Lysol.

"Unfortunately, Lysol does not act like hairspray," the 59-year-old told "It was wet and heavy. Yes, I had to start over and was very late for work."

Just last week, the FDA warned about medication errors from swallowing a topical drug: Benadryl Extra Strength Itch Stopping Gel.

The FDA had received numerous reports of "adverse events" for the drug prescribed for itchy skin. Ingesting the drug can cause dangerous levels of the active ingredient, diphenhydramine, causing unconsciousness, hallucinations and even the inability to speak.

Some of those cases were serious enough to require emergency room treatment, hospitalization or admission to the intensive care unit. And it wasn't just adults. One 26-month-old toddler was mistakenly given the Benadryl to swallow.

Packaging and assumptions about delivery of a drug can often be confusing, according to Cynthia Reilly, director of the practice development division of the American Society of Health-System Pharmacists.

"To them it looked like from past experience, a liquid would be taken orally," she said. "If it's topical, we think ointments and tubes. Calamine lotion comes in a bottle, but from a young age we know the conditions and the pink lotion."

Many consumer errors go unreported, if a patient even realizes it happened at all.

"We live in a culture with very short attention spans," she said. "At a time when we are bombarded with distractions there are an increase in therapies that are more complicated and require more attention."

Over time, pharmacists learn to be "as clear as possible," such as reminding patients to "remove the foil" before inserting a suppository, Reilly said.

Medications have also changed. Women's yeast infections are now treated orally. Ear infections no longer require oral antibiotics, but ear drops.

"People tend to have an ailment in a specific region of the body and they automatically assume they deliver it there," she said.

Coffin-Shaped Pills Warn of Syphilis Drug

Neither Reilly nor Casavant is excited about new color-coded systems for prescription medications.

Before antibiotics were available for treatment of syphilis, the drug-of-the day, mercuric chloride, was so dangerous if misused, that the pills were shaped like coffins. But special packaging can make consumers lazy, according to Casavant.

"So many times, you think you solve the problem and make the dangerous ones red or a star on a skull and cross bones," he said. "We think we are helping, but you should have to put your glasses on and read every label."

Forgetting a dose and taking a second one can also cause problems, especially with new blood pressure medicines that contain a day's worth of drugs.

"Our poison center had a gentleman call recently," Casavant said. "After taking his morning medicines he took a brief nap. On waking again, he took his morning medicines. He got not just a whole day's worth of extra blood pressure medicine, but extra doses of several other medicines as well."

The man was hospitalized with low blood pressure that could have caused serious heart problems or in a healthy child, death.

"It turned out fine, but it could have been worse," he said. "Imagine if he tried to drive to work with low blood pressure, or if the lady writing for The New York Times fell asleep driving the kids to school? Yikes!"

As for Cohen, she walked her children to school the day she accidentally took Ambien, then slept off most of the drug. What could have been a medical tragedy, turned out to have transcendental side effects.

"The pill has made me calmer, and so the girls are more easygoing," she writes. "We're on the floor creating a garden of wax, with orange tulips in magenta pots, a turquoise pond with purple frogs, a footbridge over daffodils. We leave a pavilion of red orchids until tomorrow and get into bed to read 'Sylvester and the Magic Pebble,' then wonder what it feels like to be a rock in the middle of a field. My cheek focuses on the feeling of small lips as the light goes out."

"I've been so afraid that being a mother is causing my brain to dissolve," she said. "but this morning it knew I needed to be put to sleep in order to wake up."

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