Self-Medication Dosing: Isn't It Top To Bottom?

by spotangel spotangel, DNP, RN, NP

Specializes in ED,Tele,Med surg, ADN,outpatient,homecare,LTC,Peds. Has 33 years experience.

Elderly lady confused about medication dosing. Complaints of tiredness, fatigue and shortness of breath. Is this COVID or a medication reaction?

What happens if you take the pill in the wrong order?

Self-Medication Dosing: Isn't It Top To Bottom?

The Drama Begins - The Phone Call

When I picked up my ringing cellphone, I didn't realize the drama I was going to plunge into!

It was one of the attending in the clinic, Dr. Needy. She could not get hold of anyone in the clinic ("The phone just keeps going to voicemail)", and called me on my personal cell. She wanted to get an elderly patient June, to come in and get labs done today. Apparently, June had taken too many medications last week and was still feeling sob and fatigued.

"Annie, she took 3 Lisinoprils, 3 Metoprolol, and 3 Aspirins on the same day, a few days ago!"

"She didn't bottom out or have a heart block?"

"Apparently not! I just finished a televisit today and she seemed fine but I just want to be sure and get some labs done".

"No problem! I will schedule her today and call her to come in."

By the way, she had Covid one month ago and she is off quarantine!”

“O.K. thanks for letting me know.”

Appointment Scheduled

I looked outside. It was snowing a little more intensely. The roads were slushy with brown snow. I scheduled her for the next available slot at 2 pm and then picked up the phone and called our lab in the clinic.

"Sandra, I just scheduled a patient June Smith for labs today and put her on your 2 pm slot. However, she is 79 and it's snowing hard outside. It's 10.30 am now. I am going to call her and inform her about the appointment. I wanted her to come in ASAP, get her in and out. Can you see June before her time?"

"Sure, I can Annie!"

"I'll tell her about the appointment  and to be here before 11.30 am as I know you are closed for lunch from 12- 1 pm!"

"Sounds good Annie".

I thanked her hung up, called June's home, and informed the niece Jennifer, about the appointment. This was a Friday.

“Is this urgent? Can this wait till Monday?”

“Yes, it is urgent. The doctor wants to make sure that there is no ongoing issue that needs to be fixed, like low potassium. Otherwise, June may end up in the hospital ER unnecessarily. If you bring her in today, we could check her blood and call you back if any issues by tomorrow or right away if any of the labs come back really abnormal.”

Jennifer convinced reluctant June who felt tired and wanted to sleep, to come!

Blister Pack Medication Confusion

While we waited for her to come, I reviewed her electronic medical record and noticed that she used the pharmacy on the same floor as our clinic. I spoke to Tom the new pharmacist and asked if the patient’s medications could be blister packed to avoid future mistakes.

“Annie, she is getting her medications in a blister pack. Matter of fact, I gave the niece a new blister pack last week and she seemed to understand it well. So I am not sure how the mistake was made. She apparently took the am medications for 3 days on the same day!”

“Maybe she is getting forgetful, she is 79 after all!”

“Maybe!” Tom agreed.

“I wonder if she’s taking her own meds or if someone is giving her the medications. Either way, they may need visual cues. What do you suggest?”

“How about rubber-banding it?”

“What do you mean?"

“I mean putting a rubber band on the blister pack under each day so that they know not to go below it.”

“That’s a cool idea and how about we draw a line with a red marker under each day where the rubber band would go?”

"Sounds like a plan!”, Tom agreed.

“I am coming over. Can you give me an empty blister pack and a rubber band? I’ll get a red marker.”

“No problem.”

I went over with a marker that I got from my Nurse Manager who was horrified when he heard the story. Tom who was new, turned out to be a tall 6.5 ft and hefty guy.

“I am putting that I want to be as tall as Tom on my this year Christmas wish list!” I joked.

We laughed and he gave me the empty blister pack with the rubber band. I drew red lines under each day, thanked him, and went over to the lab.

I briefly told Sandra from the lab what happened. She was horrified. Sandra and I went way back when I was an ED nurse and later on the evening manager of the ED and she was an ACLS medic. We both knew the ramifications of what could have happened when all the meds were taken together.

“She is lucky to be alive!” Sandra said amazed.

“Yup! Her guardian angel must have been working overtime!”

We both laughed.

“Anyway, here is the blister pack, marker, and rubber band. Call me when they come please.”

“No problem, I will.”

Office Visit

I got the call half an hour later and went to the lab. I saw June shuffle into the lab, her niece Jennifer holding and guiding her gently. As Sandra did the labs, Jennifer and I discussed what had happened on the day of the medication error.

“I normally give her medications but on that day, I had to go in to school as I am a teacher. So my mom who is her sister and June figured out how to take the medication! Instead of taking the morning, afternoon, and night medications that are placed in a row horizontally, she took the morning medications that were vertically placed three times on the same day! I didn’t realize till the next day when I took the blister pack to give her morning medications!”

“Ah! I see how that happened now!”

“When I asked her, she told me Isn’t it from Top to Bottom?”, Jennifer shook her head ruefully.

“I can see them both figuring it out, sisters!” Jennifer and I chuckled.

 I reviewed the “rubber band and red marker method” with Jennifer.

“This is brilliant! I am going to teach my mom and aunt. They will understand it and I have plenty of red markers at home!”

“Sounds like a plan!”

Now that the safety issue was taken care of, I wondered what her vitals was and if she needed an EKG. The shortness of breath could be from the Covid or the residue from the medication error just because she was older. It would be wise to be careful. I had not seen any follow-up appointment on her schedule. So I talked to Laura, one of the attending doctors, and put her in for a same-day appointment. She saw June and checked her out. Her vitals and EKG were perfect and the family left satisfied that everything was done and that June was safe---for now!

Problem Solved

I went back to my office realizing that it was always important to not assume that instructions were always understood. There is so much more than prescribing medications and doing a medication reconciliation. It is important to know if there could be potential complications like health illiteracy, cognitive impairment issues, inability to read or write, lack of family support, and a host of other social issues that could affect medication compliance. As we assist our patients to navigate and manage their health needs, nurses as critical thinkers should remember to investigate issues from top to bottom! In this case, June’s labs came out good and she continues to be mildly short of breath and fatigued, a residue from her recent Covid infection.

Jennifer, June’s niece reported that the rubber band method is a hit at home and June strums on her medication blister pack while she waits on her water to wash them down! Apparently, June was always a wannabe singer and guitarist who never plucked her courage to act on her dreams. Now she gets to fulfill them with her medication blister pack and her vocals although I am not sure how good she sings! June is a wise woman and knows that it is never too late to follow your dreams!


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