Ruth Marcus: A problem in need of a correction

Published: March 5, 2014

I have a particular interest in this issue because I have direct knowledge of two similar instances. In one case, the driver mistook Ambien for an anti-depressant; in the other, for the cholesterol-lowering drug Lipitor. In both cases — I wasn’t the driver — children were in the car and were able to convince the person behind the wheel to pull over. In one case, the child was mine; she called me screaming from the still-moving car that something was wrong. I don’t want to see this happen to anyone.

And it does, with horrifying regularity. Tom Brokaw accidentally took an Ambien and ended up loopy on “Morning Joe.” A Tennessee school bus driver lost her job and pleaded guilty to DUI after rear-ending a truck in a mix-up identical to Kennedy’s. Even scarier: The Israeli newspaper Haaretz reported that an El Al pilot mistakenly took a sleeping pill instead of his blood pressure medication on a flight from Kiev. (The co-pilot took over.)

Rather than prosecuting, the focus should be on preventing these incidents. Two very simple fixes come to mind: Change the pill and/or change the packaging. Look-alike pills are common, but it can’t be very hard to require that prescription sleep medication be a distinctive color or shape. Not all medications with drowsiness as a side effect, just the ones whose sole purpose is sedation.

Even easier: Pharmacies should put different colored caps — red would work — on bottles containing Ambien and similar medications. This step could be required, or smart pharmacies could do it on their own. After all, the manufacturer of my contact lens cleaner knows enough to put a red top on that bottle so I don’t mistake it for the wetting solution.

This is no grand geopolitical thought, just a small practical suggestion. It’s also one that could save lives.

Ruth Marcus’ email address is