Older man with pills, scary side effect, too many prescriptions

No one likes to make mistakes. It is a humbling experience. Even when lives are not at stake, errors can open you up to ridicule or sanctions. That’s why many people try to deny or cover up their errors. Sometimes, though, that is not possible.

Several years ago, two pilots became distracted on their way from San Diego to Minneapolis. They overshot their destination by more than 150 miles. When they realized their error they had to do a U-turn and head back to Minneapolis. They landed the plane safely, but it was an hour behind schedule. These two pilots became targets for jokes. It wasn’t long before their licenses were revoked by the Federal Aviation Administration. No one was hurt. No one died. But the pilots were severely sanctioned.

Mistakes in Health Care Are Rarely Revealed:

A little over a year ago, an article in the prestigious journal BMJ (formerly British Medical Journal, May, 2016) ignited a firestorm of controversy.  The authors suggested that medical errors were

“the third leading cause of death in the US.”

The primary author, Dr. Martin Makary, is a prominent surgeon at Johns Hopkins Hospital. In his article, he suggested that this estimate may misjudge the actual number of mistakes that are made. That’s because doctors rarely record errors as a contributing factor on death certificates.

Personal Experience With Deadly Drug Interactions:

When Joe’s mother died at one of the country’s highest rated hospitals, the death certificate described “cardiac arrest” caused by “hypotension” (low blood pressure) as a consequence of “retroperitoneal hemorrhage” (internal bleeding).

No mention was made of the various mistakes that led up to this tragedy, including a deadly drug interaction that lead to a condition called serotonin syndrome. We suspect that a failure to mention medical errors on death certificates is not unusual.

Testing the Pharmacy Safety Net:

As far as we can tell, no one has ever studied how often deadly drug interactions are listed as a contributing factor on death certificates. Doing so would likely implicate the prescribers, the nurses and the pharmacists. There is great incentive not to raise any red flags. That is as true in the outpatient setting as in the hospital.

An experiment with secret shoppers in the Chicago area revealed that pharmacies rarely catch such serious mistakes (Chicago Tribune, Dec. 15, 2016). In this test, 72 percent of the independent pharmacies dispensed dangerous or deadly combinations without warning the patient. Major chains fared only slightly better. They failed the test about half the time.

Overriding Deadly Drug Interactions:

William W. found the Chicago Tribune story hard to believe:

“This is unbelievable. Since my wife started taking so many drugs, I asked my pharmacist how they could keep track of all the interactions, and he said that the computer did that for them. I assume all software is available to all stores, so how did this happen? Just not buying the software? Maybe it should be legally mandatory.”

Virtually all pharmacies have the software. It enables pharmacists and technicians to fill prescriptions and check for drug interactions simultaneously. By the way, most physicians now have drug interaction software on their computers, smart phones and tablets. When they write a prescription, the software automatically checks for incompatibility with other medications.

The problem is that physicians and pharmacists often override warnings and alerts. In all fairness, the software frequently “cries wolf.” In other words, these health professionals get so many alerts that they tend to ignore many or even most. Sometimes that is reasonable. Other times it can be deadly.

Commonly Ignored Deadly Drug Interactions:

An example of this would be combining a blood pressure pill such as lisinopril or valsartan with an antibiotic called co-trimoxazole (Bactrim, Septra). Canadian researchers have documented such deadly drug interactions in this article in BMJ (Oct. 30, 2014).

The alert that physicians and pharmacists see on their computer, however, seems pretty mild. It is not likely to raise alarm bells or trigger a call to the prescriber from the pharmacist:

“Monitor potassium levels: This combination may increase the risk for hyperkalemia.”

What is not mentioned in this warning is that hyperkalemia or elevated potassium levels can come on suddenly and can lead to cardiac arrest. When that happens, death follows pretty quickly. It is unlikely that a death certificate from such a deadly drug interaction would list hyperkalemia or a medication mistake.

If you would like to better understand the dangers of this interaction with drugs like benazepril, captopril, enalapril, lisinopril, quinapril, ramipril, candesartan, irbesartan, losartan, olmesartan, telmisartan or valsartan and co-trimoxazole (trimethoprim plus sulfamethoxazole), here is a link.

Personal Stories & Deadly Drug Interactions:

We have already shared our personal pain over Helen Graedon’s death after a potentially deadly drug interaction. Other people have also experienced medical mistakes:

One reader shared his wife’s experience with tramadol:

“Only 50 percent errors? I am not surprised at all. My late wife filled and refilled prescriptions for Ultram (tramadol) and anti-seizure medication several times without ever hearing a word of caution. Eight doctors missed it, too.

“I finally discovered that Ultram was causing her seizures (there is a special warning about that side effect) by searching the Internet. I took the pharmacist to task. He stated that it wasn’t his job to review medications.

“The eight doctors? They just shook their heads and mumbled ‘Sorry.’ One had to be coerced to file a report with the FDA. It was a year of her life lost because of a serious adverse drug reaction.”

Another reader gave a perspective from inside the health care system:

“As a former emergency department nurse, I can tell you there are so many errors that you wouldn’t believe it! I’ve seen medication errors and worked with my share of incompetent doctors. I’ve reviewed charts that doctors have falsified.

“Once I was working in PACU (post-anesthesia care unit, formerly known as the recovery room). One patient had spent the night in the hospital and gone through an operation in which she received a transfusion. When she came to PACU, I discovered that she had someone else’s ID bracelet on! That was supposed to have been checked at least five times before she got to our unit.

“I tell all my friends that if they go into the ED or hospital, do not go alone. Call me and see if I’m available to sit with them. If I’m not available, find someone else who can be alert for errors.”

Mark S. is a retired pharmacist and shares his concerns:

“I’m a retired chain store pharmacist. In my opinion, the Chicago Tribune investigation is a huge public relations disaster for the major chains. One would hope that the dismal results of this investigation would shame the chains into making major changes. But I predict that will NOT happen.

“In my opinion, the root cause of pharmacy mistakes (including overriding significant drug interactions) is understaffing. Understaffing forces employees to work at maximum output for their entire shift. That increases the productivity of pharmacists and techs but it also causes a huge increase in pharmacy mistakes.

“In my opinion, the big chains have made the cold calculation that it is more profitable to have pharmacists sling out pills at lightning speed, and then compensate any customers harmed by mistakes, rather than have adequate staffing for the safe filling of prescriptions.

“About 20 years ago, US News & World Report did a cover story investigation that was quite similar to the Chicago Tribune’s investigation. The USN&WR cover story was titled “Danger At The Drugstore.” That cover story was embarrassing when it was published but, predictably, it had no lasting effect. One pharmacist remarked:

“The big chains will update their Policies and Procedures manual to state that pharmacists must contact the prescriber in cases of “serious” drug interactions.

“The chains hope that updating the Policies and Procedures manual will-to some extent-help protect them when some customer is harmed by a serious drug interaction. The chains will try to shift all the blame onto the pharmacist for not following the Policies and Procedures manual and calling the prescriber.

“The public should demand safe staffing levels in pharmacies but I don’t see that happening any time soon. The public has a hard time believing that things are as bad as pharmacists know they are. Pharmacies must be adequately staffed to protect the public from serious pharmacy mistakes.”

The Patient’s Responsibility to Avoid Deadly Drug Interactions:

Although the prescriber and the pharmacist have a responsibility to prevent dangerous or deadly drug interactions, patients have a responsibility too. When was the last time you asked to speak with a pharmacist when picking up your prescription? We occasionally hang out in pharmacies and observe people. It is rare to see someone engage the pharmacist in a conversation. Most folks grab their bag of pills and go as fast as possible.

“To Err Is Human”

Doctors and pharmacists are human and humans make mistakes. To learn about the most common and serious errors in the hospital, outpatient clinic and pharmacy, you may want to consult our book, Top Screwups Doctors Make and How to Avoid Them. It is available at www.PeoplesPharmacy.com

You can make a copy of our “Safe Patient Checklist” and take it with you every time you visit the doctor, the hospital or the drugstore. Always ask the pharmacist to check for drug interactions with any other medications you may be taking.

  • Take a prioritized list of your top health concerns/symptoms.
  • Ask the doctor for a recap to make sure you have been heard.
  • Take notes or record the conversation: you won’t remember everything you have heard.
  • Take a friend or family member to be your advocate and record-keeper.
  • Get a list of all your medications and supplements so that interactions can be prevented.
  • Find out about the most common and serious side effects your medications may cause.
  • Ask the doctor how confident he or she is about your diagnosis. Find out what else could cause your symptoms.
  • When in doubt, seek a second opinion.
  • Always ask your providers to wash their hands before they examine you.
  • Get your medical records and test results.
  • Keep track of your progress: maintain a diary of relevant measurements such as weight, blood pressure or blood sugar readings.
  • Be especially vigilant when moving from one health care setting to another. Mistakes and oversights are especially common during transitions.
  • Ask how to get in touch with your providers. Get phone numbers or email addresses and learn when to report problems.
  • Inquire about resources to learn more about your diagnosis or treatment.

In Top Screwups we have tips and question lists:

  • “Top 10 Tips to Stopping Screwups in Hospitals (page 22)”
  • “Top 10 Diagnostic Screwups (page 44)”
  • “Top 10 Reasons Why Doctors Screw up Diagnoses (page 46)”
  • “Top 10 Questions to Ask to Reduce Diagnostic Disasters (page 69)”
  • “Top 10 Screwups Doctors Make When Prescribing (page 78)”
  • “Top 10 Questions to Ask Your Doctor When You Get a Prescription (page 95)”
  • “Top 11 Tips for Preventing Dangerous Drug Interactions (page 108)”
  • “Top 10 Screwups Pharmacists Make (page 111)”
  • “Top 10 Tips for Taking Generic Drugs (page 139)”
  • “Top 10 Tips to Surviving Old Age (page 167)”
  • “Questions to Ask Your Doctor Before Agreeing to Surgery (page 177)”
  • “Top 10 Tips to Promote Good Communication (page 188)”

The latest study on medical mistakes from Johns Hopkins reminds us that the health care system is not likely to change any time soon. As a result, patients and their family must be proactive when it comes to preventing health care harm. We hope this book will provide you the resources you need to avoid becoming a statistic that likely would not be reported.

Share your own experience and thoughts about this article below, and please vote at the top of the page by clicking on the stars.

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  1. Linda
    PA
    Reply

    I’m so sick of hearing about opiod addiction!!! I’m a person who’s had 12+ surgeries and prescribed opioids on and off the last 10 years and NEVER put a needle of heroin in my arm ! I’ve been prescribed 800 mgs Ibuprofen ending in 10 non bleeding ulcers! I was just prescribed ultram and I’m thankful I just read your article!

    If you use opioids for chronic pain, you know the more you take the more you need to feel high! But for taking as prescribed you don’t get high and graduate to main lining heroin! I’ve seen a lot of people overdose at a young age! They made that choice to put something in their body to take away other pain not chronic pain!!!

    What is this world coming to????? Responsible people can make their own responsible decisions not Drs, Lawyers and Politicians! Lord knows they can’t make a decision and how old are they and what meds are they on????? Pissed off!!! Get to important issues!!!

  2. Susan
    Missouri
    Reply

    This is a great article. As a nurse, too many times, I have admitted people to the floor of the hospital and when I ask about medication they currently take, I am stunned to hear, “I take 2 pink ones, a white oval one, a blue one and something else for my heart.” . . That’s just in the morning!

    Knowledge is power. Hospital pharmacies, outpatient pharmacies, and even veterinarian pharmacies make errors, including the prescribers. The safe patient checklist is a powerful tool to arm oneself with to help combat and prevent mistakes that may cost someone their life.

  3. Ray
    South Australia.
    Reply

    I live in Australia and was recently prescribed “Metoprolol” by my heart Specialist. I took the script to my pharmacist, it was filled and I left. After about 1 week of taking the medication, as described on the pack, half a tablet as prescribed by the doctor.

    I started to feel really bad and I suffered extreme Atrial Fibrillation. I went to my local doctor, he was furious when reading the specialists script. It said, “Take a half tablet morning and night.” Lazy pharmacist or ignorant pharmacist?

    He said he could not read the script properly. I am a layman and could read the script OK after I learnt what to look for. Needless to say, I no longer frequent this Pharmacy.

    PS: 3 weeks after this incident, now have to take 2 full tabs per day for this condition.

  4. Dr. Judith
    Kfar Saba, Israel
    Reply

    Not only are drug drug interactions important, but also drug supplement interactions, and some drug food interactions.
    Doctors, pharmacists, and pharmacies would do well to have a patient friendly hand-out with each medicine. The current pages which come with medicines look like legal protection for the pharmaceutical companies rather than information for patients.

  5. Jim
    Florida
    Reply

    I had my 6 month checkup last week with my primary care physician. I am a chronic pain patient. He recommended Tramadol. I am glad I read this article because Tramadol is ULTRAM which I am allergic to. He knows of my allergy to ultram. I’m shocked that he would recommend Tramadol with this knowledge in hand.

  6. Sherrie
    Reply

    I would also like to know how to be sure that the medication prescribed by the doctor is the medication that you actually receive. A week ago I called in a refill prescription for my husband’s Prozac and found when I got home that it was his prostate medicine that was filled.

    Thankfully, I recognized that and called back and they just said sorry, they’d switch it for me. That’s ok but what if that was a new prescription that I had no idea what the medicine was supposed to look like. How would we know.

    When I went back for the switch of the medicine, the little girl at the counter just laughed and said they’d been making mistakes all day. (I certainly would not have admitted that.) I think they have maybe too many assistants counting and filling bottles for the pharmacist and he is so busy that he doesn’t double check.

    • sally
      WA
      Reply

      My friend’s Mom always asked to talk to the pharmacist no matter if it is a new or refill prescription. She also opens up the bottle and double-checks with the pharmacist that it is the correct medicine.

  7. Joseph
    IL
    Reply

    Is there a public website where a consumer can input all his drugs together and see the significant interactions, or is that software only available to the “professionals”?

    • Liz
      TX
      Reply

      Joseph: There’s a drug interaction checker at drugs.com, but I’m not sure how accurate it is — because I’m not a medical professional of any kind. I’d love to hear the take of a doctor, pharmacist, RN, NP, or PA on that. And if that’s not trustworthy, what’s something that is? If we’re supposed to be our own advocates, it would be nice to at least have a trustworthy place to start, at least for drug interaction info.

      [As a side note, I think it’s quite rude, presumptuous, and judgmental to infer (or outright contend) that there is something wrong with people who become addicted to opioids. Drug addiction is a disease, not a character flaw. Just as there is help for that, there is also help available to get down from horses, although the high kind usually proves more difficult.]

      • ladyliza
        Los Angeles
        Reply

        Joseph, addiction may become a disease when addicted, but the initial choices are not. We all have choices to make, and unfortunately some people make better choices than others.

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