Ask pharmacists about their number one responsibility and you will probably hear that patient safety is primary. The problem is that working conditions often interfere with that mission.

When pharmacists are pushed to fill hundreds of prescriptions each day, mistakes happen. Today’s drugstores are pressure cookers. Pharmacists do a complicated juggling act. They supervise pharmacy technicians with varied levels of skill, interface with physicians’ offices and insurance company bureaucrats, deal with drive-up windows and counsel patients.

Research has shown that high workload, distractions and interruptions all contribute to pharmacists’ mistakes (International Journal of Pharmacy Practice, Feb. 2009). As many as one in five prescriptions dispensed from community pharmacies contain some form of error (Journal of the American Pharmacists Association, March-April, 2009). Approximately 13 percent of those errors (3 percent of the prescriptions dispensed) were judged capable of harming the patient.

That may not sound like much, but if you multiply 3 percent by the 3 billion prescriptions dispensed in the U.S. each year, you come up with an alarmingly high number (roughly 90 million potentially harmful errors in filling the prescription).

Some readers of this column have had personal experience with this problem. One said: “I want everyone to know that patients should be diligent about checking their prescriptions and directed dosing information AFTER receiving them from the pharmacist. My adult son had a particularly damaging epileptic seizure that resulted in a broken jaw and all four front teeth being shattered. His jaw was wired shut for 8 weeks and as a result, he needed all liquid anti-seizure meds.

“The hospital physician handed us multiple written prescriptions upon discharge and I dropped them off at the pharmacy immediately. My husband picked them up later that night and came home with 3 huge bottles of liquid Keppra. I did a little math and found that the dosage as written on the bottles was triple the MAXIMUM dosage for someone the size of my son.

“I immediately contacted the pharmacy and explained. They reviewed the prescription on file and were mortified. The physician had written the prescription for liquid Keppra in a dosage that does not exist. The pharmacist did her best to convert the prescription into a Keppra product that does exist, but in doing so erred tremendously! Even more unsettling: that pharmacist was about to end her shift so she had a second pharmacist check her work. She failed to catch the error as well.

“Please remind your readers it is imperative not only to fully understand what has been prescribed and why, but also to verify that their prescription has been filled exactly as it was written. Pharmacists are not infallible.”

Indeed they are not. That is why it is so important for patients to check the medication and the dose against the original prescription. It is clear that the person who has the greatest stake in getting the prescription right is the person taking the drug. You as the patient have the ultimate responsibility for quality control.

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  1. Eleanor K

    How can a patient “check the medication and the dose against the original prescription” when the pharmacy retains the original prescription and/or the prescription is in
    an unfamiliar language or illegible?
    I question the pharmacist when my medicine “looks different” but that is all I can do.
    Eleanor, first you absolutely must get a prescription from your doctor that is written in English and is legible. Accepting an illegible scrawl written in Latin is so 20th Century. If your doctor won’t do it, get the nurse to print or type out the label in words you can understand.
    Make a photocopy of the legible prescription (and the instructions) and when you get your pills bottle, make sure that what is on your copy matches exactly what is written on the label. If there are any variations, make sure to ask your pharmacist what’s going on.

  2. paulbyr

    When I was in a local CVS, which also has a drive through, I was amazed at the confusion. The poor RPh was looking real stressed and through it all, a recorded reminder that said there was a customer at the drive through played about every 20 seconds. It was annoying the heck out of me so I suggested to the RPh that it might affect her work and could she have the store fix it.
    I haven’t been back during rush times since but I imagine that would be a nice help for a lawyer in a liability suit against CVS if there was an RPh mistake which harmed someone.

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