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11 Medicine Mistakes to Avoid

Common medication mishaps that could be harmful to your health  


spinner image medication bottle with several warning and instructional stickers applied
Photo Collage: AARP (Source: Getty Images)

Taking even one medication correctly and on time each day can be a challenge. In fact, research shows that as many as half of all patients don’t follow their medication instructions properly.

For older adults who often juggle multiple medicines, the challenge is even greater.

“Their regimens are more complicated,” says David Bates, M.D., director of the Center for Patient Safety Research and Practice at Brigham and Women’s Hospital and a professor of medicine at Harvard Medical School. “The more medications you take, the easier it is to get mixed up.”

With each drug having its own dosage, timing and instructions, keeping everything straight can be overwhelming. So it’s no wonder that medication mistakes happen – whether it’s forgetting a dose, taking a drug at the wrong time or misunderstanding the instructions. 

Medication mistakes can cause real patient harm, leading to poor outcomes, hospitalization or even death in severe cases. About 15 percent of older adults who seek care from a doctor or a hospital every year have suffered a medication problem, research shows; in about half the cases, the problem was preventable. AARP asked experts to identify some of the ways you’re most likely to mangle your meds, and how to prevent each problem.

1. Mistake: You skip one or more doses

One of the most common medication mistakes is skipping one or more doses, whether it’s an intentional strategy to save money or because you simply forgot. A 2021 study found that 8 percent of American adults, or about 9.2 million people, don’t take their medication as prescribed because of the cost.

While missing a dose or two might not seem like a big deal, it can have significant consequences, Bates says. For instance, if you have diabetes, not taking your insulin can cause life-threateningly high blood sugar levels.

To stay on top of your meds, set reminders on your phone, use a pill organizer or enlist the help of a friend or family member.

If cost is the issue, talk to your pharmacist about options, suggests Chad Worz, a geriatric pharmacist and chief executive officer for the American Society of Consultant Pharmacists. They can search for discounts or talk to your doctor to see if a less expensive medicine can be prescribed.

“Especially if it is a branded drug, the manufacturers might offer a way to afford it,” Worz says. “There are also a lot of programs out there to help.” 

2. Mistake: You miss a pill and then double up

Have you ever forgotten if you’ve taken a pill and popped another just to be safe? Doubling up on medicines can be dangerous, says Hedva Barenholtz Levy, a geriatric pharmacist and author of Maybe It’s Your Medications.

An overdose of a blood thinner can cause bleeding, for example, while taking too much of a beta blocker can cause dangerously low blood pressure, dizziness and fainting.

“Don’t take it if you’re not sure,” Barenholtz Levy says. “Check with your pharmacist before you take a second one or skip that day all together.”

If you know you forgot a dose and it’s a medication you take two or three times a day, you also need to consider how close you are to the next dose. “If you remember the missed dose within two hours, yes, take the medication as soon as you remember,” Barenholtz Levy says. “If it is close to the time for the next scheduled dose, then you should skip the missed dose and simply take the next dose at the scheduled time.”

To make things easier, use a pill holder that has compartments for each day. Some “smart” pillboxes even have alarms or pair with smartphone apps to deliver reminders. Another option: Some pharmacies can place your medications in blister packs or pouches labeled by day and time to make it easier to keep track of pills.

3. Mistake: You hurry out of the pharmacy

When you’re picking up prescriptions at the pharmacy, you may be tempted to grab them and go.

But pharmacists sometimes hand patients the wrong drug or dose, which can have devastating consequences. One review study estimates that dispensing errors affect more than 2 out of every 100 medications distributed by local drugstores.

So no matter how many people are waiting behind you in line, take a minute to verify that you received the right med at the dosage you expected, says pharmacist Michael Gaunt, senior manager of error reporting programs at the Institute for Safe Medicine Practices. “Patients feel pressured at the counter, but take the time to open the bag and make sure it’s the right medicine. Make sure your name is on the label, on the bottle and even open the bottle at the counter to see if it looks the same. If it doesn’t, ask questions.”  

It’s also a good time to ask any questions you have about your medications, potential interactions, and how and when to take them, Gaunt says.

4. Mistake: You crush or split pills that aren’t meant to be split

Crushing or splitting a pill seems like an easy fix if you or a family member has trouble swallowing. Patients also split pills to get a lower dosage.

However, you should always consult with your pharmacist or doctor first, because some medicines aren’t safe to pulverize or split, Gaunt says. You can also check the insert under “How supplied” section to see if the FDA has approved splitting the medication.

Extended-release or time-release medications have special coatings designed to release the drug over an extended period.

If you split or crush them, “the medicine is no longer released at a controlled rate,” Gaunt explains. “That makes all of the medication immediately available to the body, creating a risk for an overdose or having side effects like depressed breathing.”

Other types of drugs that can’t be split or crushed have coatings to help them pass through the stomach so the small intestines can absorb them or to keep the drug from irritating mucus membranes or organs.

5. Mistake: You split pills with a knife

If your pills are safe to split, don’t try to cut them with a knife or break them by hand, Bates says. You might crush them or end up with unequal pieces, he says: “You might be getting 7/10 of a dose one day and 3/10 of a dose the next day.”  

Instead, pick up an inexpensive plastic pill cutter at your local pharmacy, Bates suggests. They’re accurate and easy to use, and they typically sell for under $10.

Split pills as you need them rather than all at once. Factors like heat, moisture and humidity are more likely to affect pills that have been split, according to the FDA.

6. Mistake: You take too many pills

Taking five or more drugs at the same time, called polypharmacy, increases your risk of experiencing a medication problem or a dangerous interaction, Worz says. It’s also associated with dementia and a higher risk of falls. Plus, having all those prescriptions is expensive and makes it more difficult to take them at the right times.

Yet over the past three decades, the percentage of people age 65 and older taking five or more prescriptions tripled, from 14 to 42 percent, according to data from the Centers for Disease Control and Prevention. In many cases, older patients keep filling a prescription for decades without considering if they still need it, Worz says. Studies indicate some drugs, including certain sleep aides and heartburn medications, can get more risky with prolonged use or as you get older.

“You should always be evaluating your medicines to see if it’s time to stop them,” Worz says.

Ask your health care provider or a geriatric pharmacist to review your medications at least once a year, asking: “Is there anything I can get rid of?” Just remember to always consult with your health care provider before stopping a drug.

If you take a large number of drugs or have a particularly complicated medical history, Worz recommends reaching out to a consultant pharmacist who specializes in medication reviews for older adults. Search for one in your area at helpwithmymeds.org.

7. Mistake: You take medications with the wrong food

Some medications don’t mix with certain foods or supplements, making your treatment less effective and potentially causing dangerous side effects.

Dairy products can interfere with the absorption of antibiotics, for example, while a fiber supplement can impact the effectiveness of metformin, a diabetes drug.

Probably the most well-known example of a food that causes interactions is grapefruit juice. If you drink it while taking certain statin drugs to lower cholesterol, too much of the drug may stay in your body, increasing your risk for liver and muscle damage that can lead to kidney failure, according to the FDA.

Grapefruit juice also interacts with some drugs patients take for high blood pressure, Crohn’s disease, ulcerative colitis and abnormal heart rhythms.

8. Mistake: You take your drugs at the wrong time

Some medications, such as the osteoporosis drug Fosamax and the thyroid drug levothyroxine, need to be taken on an empty stomach in the morning to ensure full absorption. Others are better to take at night, especially if they could cause dizziness or fatigue. 

Studies show many patients fail to take their drugs at the optimum time. For example, the heartburn medications known as proton pump inhibitors are supposed to be taken 30 minutes before a meal, but researchers have found that more than half of heartburn patients don’t follow that guidance.

“So many patients aren’t following instructions on the label,” says Barenholtz Levy. “I’ll be talking with a patient asking how often they take the medicine, and it turns out they’re taking it once a day when it should be twice a day.”

Check the package insert that comes with your prescription to see if it specifies a time of day to take it, or whether it should be taken with meals or on an empty stomach – and make sure you follow those instructions, Worz says. (You can find drug inserts online at the National Library of Medicine’s DailyMed website.)

Even if there’s no time specified, you can ask your doctor if there’s a best time to take it. When in doubt, choose the time when you’re most likely to remember to take it.

9. Mistake: You keep your meds in the bathroom

Yes, many bathrooms have a “medicine” cabinet, but the bathroom is one of the worst places to keep your pills, said Barenholtz Levy. “Medicine cabinet is such a misnomer,” she says.

The heat and moisture from your shower, bath or sink can easily damage pills and capsules, causing them to become less potent or go bad.

Also, avoid direct sunlight and high temperatures, Barenholtz Levy advises. Never leave your medicine in a hot or freezing car, and if you’re traveling by plane, put your prescriptions in your carry-on bag, since the checked baggage area isn’t temperature controlled.

Good places to store medicine at home include a dresser drawer or kitchen cabinet away from any windows, the stove and sink, in a storage box or on a shelf in a closet.

If young children spend time at your house, make sure medicines are out of reach or keep them in a childproof medicine organizer or in their original childproof containers.

(Bonus tip: If your pill bottle has a cotton ball stuffed into the top, make sure you pull it out after you open the bottle. The National Institutes of Health says it will pull moisture into the container.)

10. Mistake: You consolidate your old meds into the new bottle

When you get your new pills, dumping your old ones into the new bottle may save space, but there are important reasons to keep pills in their original containers, Barenholtz Levy says.

For one thing, the label includes important information about the manufacturer and the type of pill that went into each bottle, she says. “You need to know that if there is ever a recall or if you have an allergic reaction to inactive parts of the pill,” she says.

How quickly you finish your pills can also tell you how you did with your monthly meds, Barenholtz Levy says. “If you get to [the] end of [the] bottle, it gives you a sense of, how did I do this month?”

(Don’t forget to trash medications after their expiration date, including over-the-counter remedies.)

11. Mistake: You don’t have a master list of your meds

Having an up-to-date list of your medications can save you from those “Wait, what was it again?” moments and help prevent dangerous drug interactions. Keep the list handy in your phone or stash a printed version in your wallet for emergencies.

Make sure your list includes everything — prescriptions, vitamins, supplements and any over-the-counter meds you take regularly such as ibuprofen, acetaminophen or allergy pills. Don’t forget inhalers, eye drops, ear drops and any patches you use for pain, motion sickness or hormone replacement therapy.

Also, take a moment to check that your list matches what’s in your health care provider’s portal. Consider sharing a copy with your pharmacist, too, so they can add it to their computer system and catch any potential interactions before you pick up your next prescription.

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