DRHOOK- Med mix-up: Taking wrong drug can spell doom

the handsome doctor John Hong

Mistaken identity is pretty common. Don't you hate it when you think you see a friend, and you call out her name and wave– only to receive a puzzled response from a complete stranger? 

In that situation, you can a) Pretend you're trying to greet someone else in the room, so the stranger doesn't think you were flagging her down; b) Sing a Michael Jackson song and dance so the stranger realizes you weren't flagging her down; c) Pretend you know her and can't believe she doesn't remember you; d) Crawl into a hole.

 I'm consistently mistaken for someone else. Many people mistake me for Robert Pattinson– okay, maybe not. Actually, some folks have mistaken me for a cardiologist here in town who's also Asian-American. But one patient told me, "Oh, no, you two don't look alike. He has more hair than you." 

 What happens if you mistake your pills?

 True story (and these aren't my patients): Husband and wife go to a deluxe resort for vacation. The beaches are gorgeous, the music is romantic, the pina coladas relax their minds. So they're feeling a little frisky on their 30th wedding anniversary. 

What does he do? Every night for a week, he takes a pill from a bottle labeled "Cialis." However, he falls asleep every night around 10pm, leaving his wife to rumba alone. Night after night: strike out!

 First of all, what's wrong with this story? I told my friend, "Cialis is taken once every 36 hours, so you were overdosing. Read the instructions." 

Really, though, the biggest problem was that he wasn't taking Cialis. His wife packed her Ambien CR in his old Cialis bottle. Ergo, Zzzzzz. 

I asked him, "Don't you know what Cialis looks like?" He thought it was Viagra because it was blue. First of all, why would Viagra be in his Cialis prescription bottle? Secondly, Viagra is diamond shaped, and Ambien CR is round. 

 Moral of the story: if you take the wrong pill you might get laid– literally: conked out in bed.

 This story is humorous because no harm was done except for an irritated wife. However, sometimes when people take the wrong medicines it can cause serious harm, if not death. One person I knew took a diabetic pill instead of a pain pill for a few days and become ill with hypoglycemia. A man I knew was using his wife's vaginal estrogen cream for itchy skin. (He wondered why he started to watch Lifetime movies.) 

 Everyone needs to know what their pills are and why they're taking them. If a patient shows up to the ER without a clue about what meds he's taking, it can create a dangerous situation. 

Many medications interact with others, and that can spell disaster. If you forget you're taking a beta blocker and the doctor gives you another blood pressure medicine like verapamil, you can die from complete heart block. (This almost happened to a relative of mine.)

 Knowing your medicines and what they look like can be tricky, especially with generic medicines. With generics, one refill might look different from another refill because a different company produced the pill. Pills have ID numbers on them, and there are websites to help you identify which pills you have. However, your best bet is to check your pills at the pharmacy and ask your pharmacist (although mail-in orders can make that plan pretty tricky). 

 I should write a murder mystery called, The Case of the Misidentified Medicine. 


Dr. Hook cracks a joke or two, but he's a renowned physician with an interesting website, drjohnhong.com. Email him with your questions.


1 comment

Very true and helpful, but what about ER doctors who don't check for medication interactions or medical conditions with contradictions or don't even listen to their patient before almost killing them? Happened to me in unnamed due to no free speech here ER. Or what about same hospital who doesn't write down drug allergies and adverse reactions even though they ask for them every visit, leading to overdose and serious adverse reactions? Patients have to be aware but so do doctors and medical systems have to do their part to keep their patients safe from medical errors.