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AHRQ and National Council on Patient Information and Education Produce New Tool To Help Consumers Reduce Medication Errors

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Press Release Date: April 30, 2003

The Agency for Healthcare Research and Quality and the National Council on Patient Information and Education today announced a new resource called Your Medicine: Play It Safe, to help consumers use prescription medicines safely. The 12-page brochure, available in English and Spanish, includes a detachable, pocket-sized medicine record form that can be personalized.

Medication errors can occur when a patient receives the wrong medicine, takes an incorrect dose, takes a medicine at the wrong time, or inappropriately combines prescription, non-prescription, and/or other medicines, food, or beverages. The new brochure outlines four steps to help patients use prescription medicines safely:

  • Give your health care team important information.
  • Get the facts about your medicine.
  • Stay with your treatment plan.
  • Keep a record of your medicines.

An AHRQ-supported study published in the March 5, 2003, Journal of the American Medical Association found that more than 1.9 million medication errors occurred among Medicare patients from 1999-2000. More than one-fourth of the errors were preventable. Most errors associated with preventable adverse drug events occurred at the prescribing and monitoring stages, and problems with patient adherence to prescription instructions contributed to errors in more than 20 percent of cases, according to the study.

"Safe health care shouldn't stop when a patient leaves the hospital or doctor's office. Medication errors that occur at home are a serious problem," said Carolyn Clancy, M.D., AHRQ's director. "You make a difference in learning to use your prescription drugs safely by talking with your health care provider."

Publication of Your Medicine: Play It Safe continues a partnership between AHRQ and NCPIE that began nearly a decade ago when they developed Prescription Medicines and You: A Consumer Guide, which was published in six languages. NCPIE is a non-profit coalition of more than 130 organizations committed to promoting the appropriate use of medicines through improved communication between patients and health care professionals.

"Taking medicines is rarely easy, and Your Medicine: Play It Safe can help consumers and caregivers take medicines safely. Responsible medicine use is a patient's responsibility, in partnership with their health care team," said N. Lee Rucker, NCPIE's senior vice president of policy and public affairs. "This guide encourages patients to take an active role in their health care by communicating with their clinicians and pharmacists at every opportunity."

The guide is available in English and Spanish and on the NCPIE Web site. Single copies of Your Medicine: Play It Safe are available by calling AHRQ's Publications Clearinghouse at 1-800-358-9295, or by E-mailing Bulk orders are available for purchase from NCPIE; E-mail or call (301) 656-8565.

For more information, please contact AHRQ Public Affairs, (301) 427-1364: Farah Englert (301) 427-1865 ( or Kristie Smith (301) 427-1246 (


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