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Medical mistakes happen. Hundreds, nay, thousands of them. Every day, every year. Medical treatment, it was reported in 1999, tallied up between 44,000 and 98,000 deaths that year which were directly due to "medical errors" (1). This report by the Institute of Medicine (IOM) also attributed 7,000 patient deaths annually to "medication errors."

As a result of these alarming statistics, many public interest organizations now monitor medical errors, as do medical professionals themselves. Doctors, hospitals, nurses, and other caregivers, all with an eye toward reducing deadly mistakes, have joined with at least twenty public organizations geared toward reducing the number of medical errors. The U.S. government, in 2001, established the Patient Safety Task Force to work in conjunction with other federal agencies on the improvement of patient safety.

Despite these and other efforts to stem the tide of unnecessary deaths and harmful health consequences related to medical errors, devastating mistakes still happen. It is currently estimated that approximately 1.5 million Americans suffer sickness, injury or death each year due to errors in prescribing, dispensing, or the taking of medications. Errors in the delivery and use of medications is all too common. In 2006, The Washington Post reported that, according to the latest IOM study, "on average, a patient will be subjected to a medication error each day he or she occupies a hospital bed." The cost of treating drug-related injuries just in hospitals was estimated at $3.5 billion a year.

The facts clearly point to the need for each patient to act as his or her own monitor of the care being received. Whether at home or in the hospital, a patient should know what their own prescribed medication "looks like." In hospital once, undergoing three weeks of intravenous antibiotics for severe Lyme Disease, another patient's medication was fed into my I.V. tubes. I immediately felt dizzy, disoriented, and experienced heart palpitations. Just before I passed out, I looked up at the medicine bag and saw that it was a different color from what I'd received before. When I looked at the name on the bag, it was not mine. Luckily, since I'd been hospitalized for so long, I knew how to turn off the flow of the substance into my vein. Consequently, it did not kill me. Later, I learned, it most certainly could have. This sort of error, a mix-up in I.V. medications in the hospital, happens frequently. I now regard it as

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