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2. Mrs. Nelson's Story

Here’s a story about a woman who faced challenges in taking her medicine. As you read, try to spot things that could cause her problems. 


Mrs. Nelson is 72 years old. She is a widow and lives alone, but both her daughter and son come by and call often.  

Mrs. Nelson has more than one chronic condition and has been taking the same medications with no changes for around three years.

She manages her own medicines. She gets them from a pharmacy, and remembers to take them in the right way every day, as best she can. 

She hasn’t noticed having any big problems, even with the blood thinner she takes.

One day, Mrs. Nelson heard about an herbal supplement that she thought she might like to try. It was supposed to prevent Alzheimer’s.

You may have heard of it: ginkgo biloba.

Mrs. Nelson bought it in the supermarket and started taking it every day. Why not? It was a natural remedy and all of us want to avoid problems with our memories.

A few weeks later, Mrs. Nelson was at a regular doctor’s appointment. She had several bruises on her arms and legs. Dr. Gonzales noticed them and asked about them.

Mrs. Nelson said she had been feeling a bit dizzy and had stumbled against the furniture at home. She hadn’t hit very hard and didn’t understand why those bruises had gotten so big.

Dr. Gonzales was concerned and asked Mrs. Nelson more questions about this. Had she been taking her blood thinner correctly?

(If you take blood thinners, you know how hard it can be to get this just right.)

Mrs. Nelson said yes, she was very careful about this. Then she told the doctor that sometimes her heart seemed unsteady — and maybe that was making her dizzy.

Dr.Gonzales decided to order some blood tests. Then he decided to change the amount of blood thinner Mrs. Nelson was taking because of the bruises and her blood test results.

He also listened to her heart and ordered an electrocardiogram (a test to see how her heart was beating).

Mrs. Nelson was right, her heartbeat was unsteady.

Dr. Gonzales decided to prescribe a medicine to help with this problem. He wrote a prescription for the heart medicine and also one for the lower dose of blood thinner.

After her appointment, Mrs. Nelson went to a pharmacy to get the two new medicines. She also got a refill of another medicine.

The pharmacist at Sourdough Pharmacy prepared the medicines and gave them to her in a bag.

Mrs. Nelson took them home and started to take them.

The new heart medicine was very expensive, and Mrs. Nelson wasn’t sure how she would afford it. She decided to take one dose a day, instead of two, to make her medicine last longer.

After a few days, Mrs. Nelson didn’t feel her heart was getting any better. She made an appointment to see her heart specialist, Dr. Grant.
She told Dr. Grant about the problems she’d been having with her heart.

Dr. Grant examined her and decided Mrs. Nelson needed something stronger for her heart so she prescribed a new medicine for her.

Mrs. Nelson went to another pharmacy, Arctic Meds, and filled this prescription and started taking it the next morning.

She also continued to take the heart medicine Dr. Gonzales had prescribed. She didn’t want to waste it because it had been very expensive.

Mrs. Nelson now had so many medicines that it was hard for her to remember when and how to take them.

Can you keep track of how many medications and supplements she takes now?

Her confusion didn’t help. Sometimes she forgot to take a medicine, so she took a double dose when she did remember.

Sometimes she wasn’t sure if she’d taken a medicine or not already. She wasn’t sure what to do, but she didn’t want to tell anyone.

After a few days, Mrs. Nelson was feeling even dizzier and she was feeling very confused and forgetful. 

This made her even more worried about the possibility of Alzheimer’s, so she started taking more of the ginkgo biloba.

Then Mrs. Nelson’s son Jason came to visit. Mrs. Nelson stood up to go make tea. She was suddenly very weak – her legs buckled and she fell.

She hit her face and got a nosebleed that they couldn’t stop. It was very scary.
Jason took her to the emergency room. Mrs. Nelson was admitted to the hospital.

After days in the hospital and lots of tests, the doctors finally discovered that all of Mrs. Nelson’s new problems were caused by medicine mistakes.

A medicine mistake is just what it sounds like — any mistake that involves a medicine.

These mistakes may cause serious harm, or they may not.  

The medicine mistakes that Mrs. Nelson experienced were:

    1) The ginkgo biloba interacted with her blood thinners, making them have a stronger effect on her.
    2) She kept taking the first heart medicine along with the second.
    3) Sometimes she forgot doses, sometimes she doubled up, and she only took half the dose of her first heart medicine.
    4) The pharmacy accidentally gave her the wrong medicine. The names of the two medicines sounded very much alike and it was a little hard to read the doctor’s handwriting. This does happen sometimes.

So what happened to Mrs. Nelson because of these medicine mistakes?

    • The combination of the gingko biloba and heart medicines caused her bleeding and bruising, heart unsteadiness, dizziness and confusion.
    • The incorrect medicine from the pharmacy mix up also caused some heart and confusion problems.
And then of course she went through
    • extra doctor’s visits,
    • paying for more medicine,
    • a trip to the emergency room,
    • being in the hospital, and
    • all the tests.

Even with Medicare, this was expensive — and caused a lot of worry and stress. And it was all preventable.

Many of us feel that because doctors or other health care providers are the experts, they are in charge of our health. They tell us what we should do and we are responsible for listening to them.
…we may
    • see more than one health care provider, often only for short amounts of time.
    • get our medicines from different places.

Let's look at Mrs. Nelson's care team:

In the middle, we see Mrs. Nelson — and there’s the gingko biloba she bought for herself.
Around her we see some of the other partners on her health care team: both of her doctors who prescribed medicine for her, and both of the pharmacists who filled the prescriptions.

    1. Who is the only person in this picture who knows everything Mrs. Nelson is taking?
    2. Who knows that she sometimes misses medicines and then takes a double dose?
    3. Who knows it is hard for her to remember how and when to take all of her medicines?
    4. Who knows that sometimes she can’t afford all of her medicines?

Yes, the answer to all the questions is Mrs. Nelson.

    • She is the only person in the team who knows what problems she has buying and taking
      her medicines.
    • She is the only one who knows everything she is taking
    • Her doctors and pharmacists can’t prevent mistakes and make sure she gets the right medicine
      without her as an active part of the team.

Just for fun, here’s a cartoon that shows a near miss on a medicine mistake.

    Preventing a medicine mistake! 

              © Brian Crane Dist. by The Washington Post Writers Group

Back to Mrs. Nelson's story...
So what were some of the things that Mrs. Nelson did that her providers would have wanted to know? 

Mrs. Nelson isn’t the only one who makes medicine mistakes!
How common do you think medicine mistakes are? How serious do you think they are?

A survey found that these problems happened for Americans of all ages, with all different kinds of health issues.

And it’s not just the people taking medicines or their caregivers who make mistakes… as we heard in Mrs. Nelson’s story, professionals occasionally do too. That’s why it’s good to check your medicine labels to make sure you have the right prescription.

Medicine mistakes:

    • hurt 1 ½ million people every year,
    • cause 1 in 3 medicine-related hospitalizations
    • and they cause nearly 125,000 deaths each year.

Have you ever experienced a medicine mistake? 

The good news is that we can prevent medicine mistakes by:

    • learning to manage our medicines, and
    • being an active partner with our health care team.

Read on to learn how to do both!