Key Takeaways

  • Alice Brennan, a vibrant 88-year-old who died tragically at the hands of preventable medication harm and system failures, leaves a legacy of how to protect yourself and your loved ones.

  • Bring your medication lists to the hospital, know what the “pills in the cup” are for, ensure that the “right patient check” happens every time you receive medication, and remember that new symptoms could be drug problems.

  • Don’t assume just because you are in the hospital the correct information about your medications and an accurate account of your medication history will be available.

No matter how active and healthy we try to be, the likelihood of having a hospital stay increases as we age.

Hospitals are busy places with staff working tirelessly to care for patients with a variety of issues, especially during the winter months. Being hospitalized unexpectedly can be especially overwhelming for you and your family. You cannot assume that every health care facility or staff has accurate and up-to-date information about your health. 

How medication errors happen in hospitals

In many areas of the country, hospital computer systems are not linked to your doctor’s computer system. Unfortunately, your information can slip through the cracks—don’t let your health and safety be one of them. Your responsibility as an active participant in your health care is to not let your treatment be overlooked. Don’t be caught unprepared. Arm yourself with information before a hospital stay surprises you.

In the case of Alice Brennan, she was given a muscle relaxant called cyclobenzaprine (brand names Flexeril, Fexmid, Amrix) in the hospital without her or her family knowing because it was on an old medication list in the hospital's computer system. The hospital team (who did not know her) saw it on their list and assumed she needed the medication. She didn’t. In fact, Alice had never actually taken that medication because her neurologist (who knew her well) had told her it was not safe for someone her age. 

Because of this error, Alice experienced symptoms she never had before, such as confusion, hallucinations, sudden loss of appetite and thirst, dizziness, falls, and eventually this led to infections she acquired during her hospital stay. All of this led to her tragic and untimely death.

What we can learn from Alice's story is to be aware of potentially deadly medication errors. Be prepared for your hospital stay with these helpful tips.

Have an updated medication list

  • Don’t assume that your hospital team will have your correct medication information and an accurate account of your medication history just because you are in the hospital.
  • When you go into the hospital, always take an updated list of your medications with you. There should always be one on you, as you never know when you might unexpectedly end up in the hospital.
  • As a backup, a loved one or someone you trust should also have an updated copy.
  • Make sure you also carry an allergy list. This should also include any medications your doctor may have told you never to take. These are called “Never Meds.” You may not be allergic to the drug, but this may be the only way a medication harmful to you can be flagged by hospital staff.
  • If you are unsure how to create a medication list, check out this NCOA template, or have your local pharmacist print one off for you. That way, you can also ensure that your pharmacist has an accurate history. 
  • Keep an updated medications list with other important paperwork (e.g. living will, power of attorney) for easy retrieval.  Programs such as File of Life or Vial of Life provide resources that can help.

Be proactive about what meds are being given to you in the hospital

When a nurse brings your medications in a little paper cup, be sure you know what “the pills in the cup” are for before you take them.

  • Thoroughly examine each medication and ask questions, especially if you notice any differences from your usual medication routine at home. Some things to look for:
    • The pills look different in shape or color.
    • The pill amount is more or less than the number of medications you typically take.
    • There are new pills that you do not recognize.
  • If you notice any differences in “the pills in the cup,” ask questions.
    • What are these medications?
    • Why are you are being asked to take them?
    • What are the potential side effects?
  • Also, be aware of any medications given to you in an IV. Ask questions to gain a greater understanding of what those are, too.
  • You and your family should never be confused about your medications in the hospital. Ask questions and know what they are for before taking them.
  • It may be helpful to bring a notebook to keep track of any changes made to your medication routine while in the hospital. Use it to keep a diary of any new symptoms you experience. They might be related to the reason you’re in the hospital, but they may also be side effects of new medications.

In the hospital, insist on the "Right Patient Check"

Before you take any medications, insist on the “Right Patient Check” every time. A busy, overworked nurse might accidentally bring you a different patient’s medication!

That patient check means that before you take your medication,  you are asked:

  1. Your full name
  2. Your birth date
  3. OR your wristband is checked 

Be alert to new symptoms

  • New and abrupt medical symptoms could be warning signs of medication problems, especially if the symptoms you are experiencing have never been a problem before.
  • If this happens to you,  the new symptoms you are experiencing could indicate that your body is not reacting well to a medication.
  • If you think you might be experiencing a medication problem, talk to your doctor or someone in charge of your medications.
  • Make sure you or your care partner’s concerns are heard. Be persistent, and do not stop until someone can prove to you that the symptoms you are experiencing are not side effects of medication.

Talk to your hospital's social worker

Social workers:

  • Are patient advocates who can help you navigate the complicated health care system.
  • Facilitate conversations between you, your doctors, and your family about your medications (including “Never Meds” that should never be prescribed to you) and any other concerns.
  • Can help you better understand your treatment options and your rights as a patient.
  • Connect patients to helpful community resources.
  • Coordinate discharge and may follow up with patients after a visit to ensure that their needs are being met.

What to know about hospital discharge

Befor leaving the hospital:

  • Make sure you understand your discharge summary and feel comfortable and capable of following all of the instructions.
  • Get a discharge medication list that has any changes to your medication, including new medications, dosage directions, and reason for the prescription. Specifically, know which medications you are to STOP from before your hospitalization, which ones to CONTINUE and which ones are NEW.
  • Update your medication list(s).  Be sure you share your updated medication list with your doctor(s), pharmacy and caregiver.  Make sure they are aware of your STOPPED, CONTINUED, and NEW medications and discuss any medication changes with them at your first visit after hospitalization.  Especially let them know if you think any NEW medications are causing any adverse effects.

When you get a bill in the mail, do you look at it carefully? Don’t you think you should do the same with your medications? Your life may depend on taking charge of your medications, especially when you are in the hospital and when you are discharged. It is important for anyone taking care of you in the hospital to know when you feel something that doesn’t seem right. It could be a new medication problem. Your doctors and care team rely on you to help them help you.

This is an article in a series from Team Alice, a project of The Center For Successful Aging at the University at Buffalo. Please visit Team Alice’s YouTube page for more information on medication safety.

Funding for this research was provided by RRF Foundation for Aging Grant #2019060 and USDeN NIA R24AG064025 subaward STE2196-17.