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 ;)
About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark 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. He lives in San Antonio, Texas.