The Wrong Answer

One reporter's experience with misdiagnosis

I blame my mother.

I was feeling fine that February afternoon. Excited about my upcoming study abroad trip to Australia the next week, the last thing on my mind was a doctor's appointment.

But the nagging cough that tickled my throat was too much for my mother to bear. Off I went on a harmless trip to see my former allergist. Turns out, I had what my doctor thought could be a small virus. I received a prescription for Cingulair. I dutifully took a pill each day, doubting what good it would do. A week passed, but the cough did not. Less than 24 hours before takeoff from Chicago, I was back on the examination table.

Feeling confident, perhaps even cocky that nothing was wrong, I smiled as the nurse slid the digital thermometer under my tongue. I should have known from the look on her face that something was up.

"You know you have a fever of 102, right?" she said.

I didn't believe her until she showed me the digital screen glowing "102.0."

In walked my now-concerned doctor. It only took a few minutes to confirm the diagnosis: an inflamed respiratory system bordering on the early stages of pneumonia — not exactly good news for someone about to embark on a trip halfway around the world.

Out came the prescription pad and new prescriptions for two different medications. But it was too little too late. The next five days of travel and settling down in Australia featured fits of exhaustion, lack of appetite and a continued cough. Within a week I was fine, but I would have loved to have those seven days back.

Whether it was a misdiagnosis or a virus that simply resisted medication, my experience is the closest I have ever come to receiving an incorrect prescription. Looking back, I consider myself lucky compared to the 7,000 Americans who die annually because of incorrect prescriptions. I am only a needle in the haystack of the 1.5 million Americans who are sickened by medication errors each year.

Doctor error is not always the root of the problem. While physicians often prescribe the wrong drug, the wrong amount or the wrong route of drug administration, pharmacists also make mistakes. Pharmacists face packaging and labeling errors, outdated or incorrect drug information and confusing drug names.

Risks are present in the home as well. Patients receive incorrect instructions on when to take pills, how much to take and how to take them.

Medicating errors plague hospitals in particular. An estimated 1.2 million medication errors take place in nursing homes and hospitals annually. The averaged hospitalized patient experiences one medicinal error per day.

Local medical institutions are not exempt from these issues. The Cayuga Medical Center in Ithaca, N.Y., dispenses over 95 percent of its medications without issue, says pharmacist Michael D. Judd. That leaves nearly 1,500 medications in question, but many of these are small mistakes that result in no harm done. The center has had no cases of permanent damage or death due to medication errors.

Dr. Judd says a rigorous review system ensures that most patients are medicated properly.

"All nurses are trained to use the 'five rights' before administering any medication to a patient:  right drug, right dose, right route of administration, right time, and the right patient," Judd said.

More importantly, the center relies on a punishment-free review process to determine the root cause of medication errors. As a result, many mistakes are caught before they even can take effect.

"Many of the medication errors that we track never result in an inaccurate dose or wrong medication reaching the patient," Judd said. "We even count 'errors' that are caught before the medication is pulled from the shelf such as unclear handwriting."

Relying on a computerized ordering and dispensing system has helped improve operations. It also gives Cayuga Medical Center administrators the opportunity to benchmark their data with national statistics. Given an error rate of 5 percent that compares with national statistics from 1992, there is still work to be done.

Otherwise my next trip to the doctor won't be very comfortable for myself and my mother.