To Frank(not his real name), and thousands of others like him, difference is a matter of life and death. Our story begins when Frank was admitted to a hospital with breathing difficulties. His physician ordered usual breathing treatments, tests and medication.

After a few days in hospital, Frank's recovery had progressed steadily, but he still wasn't strong enough to return home. Arrangements were made to admit him to a skilled nursing facility for continued care and convalescence.

One of medications doctor prescribed for Frank was Bumex, which is typically used to treat respiratory problems such as those experienced by Frank. The doctor ordered Bumex one time, every other day. That is exactly what was written in his medical chart: "Bumex, 1 tablet, QOD" (QOD is Latin abbreviation to indicate "every other day").

When Frank was transferred to skilled nursing facility, a copy of his doctor's orders accompanied him. These orders were typed and placed in an envelope. When Frank arrived at facility, nurses on duty opened envelope and noticed that Frank was taking Bumex, 1 tablet, QID. Remember, Frank's doctor had ordered Bumex, 1 tablet, QOD. In transcription of orders, someone accidentally typed "QID." What's big deal, you might ask?

In medical language, QID means four times a day. So at skilled nursing facility, instead of receiving this extremely powerful medication every other day, he was being given eight times ordered dosage. Within a week, Frank had died.

Frank's story is an example of a tragic but avoidable situation. To prevent these types of scenarios, we must take an active role in our own health care, especially when dealing with medications. Our health care system demands that we comply with strict and often confusing instructions about medications. Without an organized system in place, unforeseen medication errors can happen.