From the January 2009 issue

A patient was accidentally given another patient’s medications. Later, when a pharmacist realized the mistake, he attempted to reach the patient by phone. However, the patient did not answer. The pharmacist kept trying but did not get through until later that evening. By that time, the patient had already taken another patient’s CELLCEPT (mycophenolate mofetil), an immunosuppressant, instead of her new prescription for ZESTRIL (lisinopril) for high blood pressure. This episode reminded us that with all the communication technology available today, we mostly ask for a patient’s home phone and maybe their business line but not necessarily their cell phone numbers or email addresses. It makes sense to ask for these other modes of contact for emergencies like the one described.