Thankfully, it was nothing harmful or that dangerous… but I committed a medical mistake on myself last Saturday.
I tweaked my lower back last Wednesday – something that, thankfully, isn’t a chronic problem (but I did just turn 40). It got progressively more painful over the next few days, so I went to an urgent care clinic on Saturday.
I was given a prescription for a muscle relaxant and was told I could continue taking Ibuprofen. Saturday afternoon, I took the muscle relaxant… and got incredibly sleepy almost immediately…
Sunday morning, I went to go take more Ibuprofen… and discovered that I had been taking Ibuprofen PM during the day Saturday… and had taken some before taking the prescription medication.
Oops. The Ibuprofen PM has a sleep aid in it.
I took the muscle relaxant Sunday afternoon… not incredibly sleepy. So, I guess it WAS the Ibuprofen PM.
Dr. Deming and the Lean approach teach us to blame the system, not the individual when something goes wrong.
In this case, I was the system. I have nobody to blame but myself. I know I should have read the front labels, but I was in pain and both bottles were on the countertop, so I only saw them from the top… and I grabbed the wrong one. I’m human. Mistakes like this happen.
But, still, here is the countermeasure I am taking…
The two bottles, the regular Ibuprofen and Ibuprofen PM look the same on top, even though they have very different labels. The pills look very different and, if I was taking Ibuprofen regularly, I might have already learned that the nighttime formula was blue. The labels on the front of the bottle are very different, of course, but I missed the “PM.’
OK, so now I know the blue pill is the PM formula. But, still, I decided to mark the top of the bottle as a preventive countermeasure for the future:
You might think there’s a risk of putting the wrong cap on the wrong bottle… but they are different and wouldn’t fit each other.
I think I’ll be avoiding this mistake again.
Note that my countermeasure did NOT include putting up a warning or caution sign in my bathroom.
Now I need to think of good countermeasures for not hurting my back again!
The yellow / blue color coding is used pretty regularly to indicate if cold medications are daytime (yellow) or nighttime (blue), but this standard isn’t always followed, as Eric Willeke said:
@MarkGraban did you get the yellow pills for nighttime congestion like I did? Switching off-brands killed performance ;)
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About LeanBlog.org: Mark Graban’s passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all.
Mark is a consultant, author, and speaker in the “Lean healthcare” methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. Mark is also the
VP of Customer Success for the technology company KaiNexus.