A 40-year-old woman who noticed a medication error.

Ms K is a 40-year-old woman who found an er-rorwithherprescribedmedications.ShewasdiagnosedwithHIV infection in 1996 and has taken several different drugregimens. Despite the complexity of her drug program, MsK has been able to manage it well. She has taken an activerole in understanding the benefits of her medications andhas not had major adverse effects.MsKhadaskedthatrefillsforherprescriptionsbecalledin to her pharmacy. When the time came to take her newlyfilled prescriptions, she noted that 2 of the drugs were un-familiar to her, and that 2 of her HIV drugs were missing.Ms K immediately called her primary care physician,DrT,toreportthisfactandhavetheerrorrectified.ShewasconcernedaboutcontinuingherplannedHIVregimenwith-out interruption. The error was confirmed: Stelazine (tri-fluoperazine) and ranitidine had been dispensed to herinstead of stavudine and lamivudine.Thecorrectprescriptionswerethencalledintothephar-macy.Fortunately,MsKwasabletocontinueherdrugregi-men uninterrupted and did not experience any harm fromthis event.Overthepast4yearsMsKhasdoneremarkablywell.Sherecentlymarriedandchangedhercareerdirection.Shedoesnot smoke or abuse alcohol or illicit drugs. Her medica-tionsincludelamivudine,150mgtwicedaily;stavudine,40mgtwicedaily;efavirenz,600mgatbedtime;abacavir,300mg twice daily; pentamidine, 300 mg monthly via nebu-lizer; ethambutol, 1000 mg/d; and clarithromycin, 500 mgtwice daily.MS K: HER VIEWSI have a regular medication regimen, a big one, because I’mHIV-positive. So I rely on my medications and have to getprescriptions every month. I picked up the medication. Ididn’t look in the bag for about a week. When I opened thebag, I had 2 completely wrong medications. One was an ul-cer medication and one was a tranquilizer, but they weresupposed to be antiretroviral medications.It was very frustrating because I count on these people todo it right and count on having the right medicines. The ag-gravation of having to go through that process again is likecontacting City Hall. I think that you have to be an informedconsumer of the medical system. I didn’t lose confidence inthe system—I always thought it was poorly run. I go to thehospital because the doctors are very good, but the system isverypoor.IfIranabusinessthewaythehospitalisrun,Iwouldbe out of business. The hospital is like a mill—it’s deperson-alized. The error was just indicative of my feeling about theprocess—it reinforced that no one is watching the store.As much as I go to the same pharmacy every month andbuy the same medications, I remain very anonymous. I waswondering,howmanypeoplespend$15000ayearatthatphar-macy? Those are the customers who should be treated prettywell. But, to them, you’re just another packet of pantyhose.The disturbing part of the whole thing for me is, what if Ididn’t know better not to take those medications—supposeit was the first time I ever got them—and I took them. Luck-ily, I’m an informed consumer of my medications. But forsomeone who is not, it could have been disastrous.DR T: HER VIEWSThere’s no question in my mind that this case was a nearmiss.Inthevastmajorityofcases,itwouldhavebeenagraveerror had an intelligent, astute patient not caught it.Iwasquitedisturbedtoseehowcompletelyunrelatedthemedication she received was to what had been prescribed.I mean, stavudine and Stelazine sound somewhat similar,but lamivudine and ranitidine are not that close. I checkedhermedicalrecordtoseewhatwehadlistedashavinggiven