a pharmacist at work behind the counter of a pharmacy, mistake, atenolol shortage

We have been stunned by the number of mistakes that occur in pharmacies. A few years ago we asked the question: how many errors occur annually in drug stores? What we discovered was beyond shocking. One study found that the average pharmacy fills four prescriptions incorrectly each day. The researchers estimated that this would add up to 51.5 million errors annually (Journal of the American Pharmaceutical Association, March-April, 2003). Another study carried out with trained secret shoppers uncovered an even higher rate of mistakes. One out of five prescriptions dispensed deviated from the physicians’ written orders (Journal of the American Pharmacists Association, March-April, 2009). Using that calculation, hundreds of millions of errors occur annually in pharmacies.

Such numbers are unbelievable. And yet most patients hardly bother to look at the little bag of medicines they receive from the pharmacist before heading out the door. Dennis Miller, RPh, is a retired pharmacist. He provides an insiders perspective on this huge problem in the article below.

Dennis Miller, RPh, Compares Banks to Pharmacies:

I admit up front that I am not an expert on the frequency of bank errors. I’ve never worked at a bank. I’m basing this article on my perception of banks from the perspective of someone who is 65 years old and has relied on banks like most people.

How often has your bank given you the wrong amount of money when you cashed a check? I don’t recall a bank ever short-changing me or giving me too much cash.  Most people trust their bank teller, but they almost always count the cash to verify that no mistakes were made.

Patients are Far More Trusting of Pharmacies:

My impression is that pharmacy customers assume that the incidence of pharmacy errors is similar to the incidence of bank errors, i.e., a pretty rare occurrence.

I suspect that pharmacists are far less confident about their own accuracy in comparison to the confidence our customers have in us. The difference is that pharmacists know the infinite number of things that can go wrong at the pharmacy.

Let’s contrast banks with pharmacies:

The most obvious thing about pharmacies is that they have thousands of products on their shelves. In contrast, there are no products on bank shelves. Banks deal primarily with one product: money.

Bank managers have a much better way to precisely gauge the accuracy of tellers than pharmacists have to gauge their own accuracy and that of technicians. That is largely because bank tellers must balance their drawers at the end of their shift. If the teller is over or short by a significant amount of money, there is likely to be an intensive investigation by that teller, the head teller, and/or a bank officer.

In contrast, with the notable exception of some controlled or “scheduled” substances (like Ritalin, Percocet, Oxycontin, etc.), pharmacies do not “balance” or reconcile their inventories at the end of each pharmacist’s shift.

At the pharmacy chain I worked for, we were required to maintain a running balance of each Schedule II drug. In effect that forced us to count the remaining inventory of the specific Schedule II drug after we dispensed some quantity of that drug.

Keep in mind that Schedule II drugs account for only somewhere around 5 per cent of the total pharmacy inventory (just a guess). There are far more pills in the pharmacy that are not controlled substances. That includes drugs for blood pressure, cholesterol, type 2 diabetes, depression, skin problems, seizures, as well as oral contraceptives, antibiotics, acid suppressors, etc. There is no running inventory kept of drugs in these non-scheduled categories.

Grabbing the Wrong Drug:

Pharmacists aren’t able to “reconcile” their inventory of non-scheduled drugs in any way similar to the way that bank tellers “reconcile” (balance) their cash drawer. Whereas there is only one product that bank tellers handle (money), there are thousands of products that pharmacists and technicians handle.

Due to understaffing, simple carelessness, look-alike / sound-alike drugs names, poor handwriting, and other factors, we mistakenly grab the wrong drug far more often than you would believe.

Pharmacies use technicians because it is much less expensive to hire techs than it is to hire additional pharmacists. These technicians vary in ability from those that are super-competent to those that are an accident waiting to happen.

One Pharmacist vs. Lots of Bank Tellers:

Customer wait time is directly proportional to staffing levels. The big chain drug stores want to keep the number of pharmacists on duty at one time down to one if at all possible, since they are so expensive to hire. In contrast, banks can have multiple tellers on duty because they earn much less pay than pharmacists.

Corporate management at the big chain drug stores pressures pharmacists and technicians to fill prescriptions quickly. There are lots of production metrics in chain drug stores (for example, the number of prescriptions filled per hour and the amount of payroll utilized in the process).

Speed vs. Accuracy:

A pharmacist’s speed in filling prescriptions is a major factor used by supervisors in evaluations of pharmacists. A pharmacist who always has long lines at the pharmacy whenever the district supervisor is in the store is likely to be admonished by that supervisor and/or be given a poor evaluation by that supervisor.

Efficiency metrics in the pharmacy include things like answering the phone by the third ring and regularly informing any callers placed on hold as to the status of their call.

Racing the Red Light:

Some pharmacy chains have a red light on the computer screen which alerts the pharmacist that it has taken a long time to fill a prescription once it has been entered into the system. Pharmacists derisively refer to this as “racing the red light.” I did not work for a chain that had such a red light, but I am told that pharmacists would be admonished by their district supervisors when the red light frequency became excessive.

Thus I suspect that there is far greater pressure on pharmacists to fill prescriptions quickly than there is on bank tellers to complete customer deposits or cash checks.

I suspect that most pharmacists perceive corporate management at banks to be more concerned about accuracy than corporate management at chain drug stores. Bank tellers must be careful to dispense the correct amount of cash, whereas pharmacists have to be careful that we dispense the right drug, the right quantity, the right directions for use (once a day, twice a day, every 4 hours, etc.). We also have to screen for potential drug interactions and for drug allergies.

Drive Thru Disasters:

Whereas bank tellers don’t need to tell customers how to spend money, pharmacists often must advise customers about the optimal use of drugs, including adverse effects to watch out for, the best time to take medications, foods to avoid, the need to avoid alcohol or excessive sunlight, and the fact that a medication can make driving or operating machinery dangerous.

Banks have had drive thru windows for a very long time. Many pharmacists feel that the drive thru window is the worst thing that ever happened to our profession. Drive thru windows cause the public to think that drug stores are no different from fast food outlets, where speed is the primary objective.

One of the banks I use is not very busy and, at times, there is only one teller on duty. He or she must wait on customers inside the bank as well as those at the drive thru window. I am sure that this is stressful to the teller. But that teller has to balance his/her drawer at the end of his/her shift. Thus the manager at that bank knows when the teller has made an error or errors.

In contrast, pharmacists don’t necessarily know precisely what errors we make unless, for example, a customer returns to the pharmacy asking why the pills we dispensed look different from what they are accustomed to.

Pressured by Patients:

I don’t know whether bank customers are more (or less) impatient than pharmacy customers. I know that pharmacy customers routinely increase the stress level on the pharmacy staff by clearing their throat, by clanking their keys on the counter, by honking their horn at the drive thru window, and by asking “Why does it take so long to put a few pills in a little bottle?”

Understaffing is the key concept that explains why working at chain drug stores is so stressful. The big pharmacy chains have chosen understaffing as their road to financial success. Understaffing forces all employees to work at break neck pace. But understaffing unquestionably increases the incidence of pharmacy mistakes.

Most of the pharmacists I know believe that the big pharmacy chains have made the cold calculation that it is more profitable to pay customers harmed by pharmacy mistakes, rather than have adequate staffing on duty so that pharmacy mistakes are a rarity rather than a common occurrence.

Do you rush your bank teller when he/she cashes your check or processes your deposit?  Do you rush your electrician when he is rewiring your circuit breaker?  Do you rush your mechanic when he is working on your brakes? Do you rush your barber or hairdresser when he/she is working on your hair? Do you rush your dentist when he/she is filling your teeth?  Do you rush your accountant when he/she is working on your taxes?  Do you evaluate your cardiac surgeon based on the amount of time he/she takes to complete a triple bypass?

My point is that, for some reason, pharmacy customers seem to feel it is no different to rush one’s pharmacist than it is to rush a clerk at McDonald’s, Burger King, or Wendy’s. Many pharmacists feel that our customers’ impatience originates from the addition of drive thru windows at pharmacies.

A Pharmacist’s Dream:

My hope is that pharmacy customers have as much patience with pharmacists as they do with bank tellers, electricians, barbers, mechanics, dentists, accountants, plumbers, etc. The consequences of a pharmacy mistake can be far more serious than an error caused by most other workers in our economy.

Pharmacy mistakes are far more common than you would believe. The solution to this problem requires that pharmacy customers be more patient, that chain management be less obsessed with production metrics, and that state boards of pharmacy exercise courage in standing up to the immense legal and political clout of the mighty chain drug stores. State boards of pharmacy are doing a miserable job in protecting the public safety by failing to mandate safe pharmacy staffing levels.

Please keep all of this in mind the next time you are tempted to rush your pharmacist. Please don’t forget that pharmacies are not like banks or fast food restaurants. The worst thing you can say to your pharmacist is to hurry up because you have ice cream sitting in your car because you’ve just come from the grocery store.

Written by Dennis Miller, RPh

Comments welcome below.

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  1. James B H.
    North Carolina
    Reply

    I am clinical psychologist and endeavor to keep up to date on psychopharmacology. I am dismayed that there are typically three names for each drug: the chemical name, the official name, and the trade name. I have discovered many errors: one involved two physicians Rx for the same med, same dose, but with two versions of the drug’s name. The pharmacist didn’t catch it either. This puts unnessary stress on clinicians. Bank tellers have a finite number of entities to deal with, even if they are handling multiple currencies, and they are all denominated in decimals.

  2. Lea
    TX
    Reply

    I worked as a tech in a grocery store pharmacy for one day, and at the end of my shift said “No thanks.” The stress was horrible. The required pace was insane. I told management I felt like the situation was dangerous because deadly mistakes could be made. That was years ago, and considering the state of health and insurance in this country, it’s probably worse now.

  3. B
    Mooresville, NC
    Reply

    I spent a career working in banks. Someone hit the nail on the head — top management at banks realized 99.9% accuracy in conducting their business was not good enough — they had to be 100%. They build processes, training, and their business model based on that concept. Guess the top management of big pharmacy chains have a different priority. I have had to take at least one prescription back — the pills just did not look like the ones I had before under the same prescription.

  4. G. R. B.
    Reply

    I’m biased. This writer has nothing but praise for pharmacists since my father, Ray, ran several locations in Fla for many years, and I took over his last one after he passed. These were the late days of “compounding” or very specific remedies, as per specialists or doctors. The pharmacist was, and is, the best source of medication information. They will give you the time that you won’t get at your doctor’s office by an underpaid staffer.

    There are three problems: terrible U.S. health access, big pharma/chain stores/mailorder and clueless patients. That’s YOU! Folks, many of these are quite complex compounds with side effects and contraindications that even the physician doesn’t know of. Best advice is to talk to the pharmacist rather than your banker. Ha! A pharmacist knows solid info, welcomes the attentive, proactive patient, and will usually give straightforward direction on how to proceed. Some of these drugs might not be good for you, or conflict, and they will usually inform you of that effect. Take care of yourselves out there.

  5. Susan
    Reply

    I have caught two or three mistakes in prescriptions over the years, but never knew of this extent. From now on, I will never be impatient at the pharmacy counter, and I will check the contents of the bag before I leave the store. Thank you for this eye-opener!

  6. LI
    Reply

    You do not have to wait to examine your medications until they are in the stapled bag, which would presumably be after you have paid for them. The staff (pharmacists and techs) at the pharmacy that I have patronized for years know to hand me the medications first so that I can examine them for the proper medication, dose, generic manufacturer, amount, and number of remaining refills. If you have a preferred manufacturer, ask the pharmacy whether they can order from that manufacturer for you. Often they can.

  7. Ron
    SoCal
    Reply

    My local pharmacy has made several mistakes over the years, including shorting me (by a lot) of Diazepam for vertigo. It was one particular pharmacist. He is no longer employed there. A new pharmacist at the same store shorted me one half of prostate meds. Another gave me the wrong type heart medicine. Always check and count.

  8. Eusebio
    El Paso, Tx
    Reply

    What about prepackaged pills like in Mexico?

  9. Kirk
    St Paul MN
    Reply

    I was a retail pharmacist for nearly 30 years, and have seen a good profession ruineded by third party insurance and chain drug stores. The chains for the most part accepted any third party insurance, even if reimbursements didn’t exceed costs. Insurance went from being 25% of the business to nearly 100%.

    Drug prices (acquisition cost) inflated at enormous rates (400% and more) as pharmaceutical manufacturers took advantage of being isolated from the buying public by 5 or 10 dollar copays for drugs, and have continued, in some cases criminally, to take advantage of their monopoly and artificially inflate drug prices. And, where there’s money, there are lawyers, suing drug companies for damages, which only adds further to the drug cost.

    I don’t believe any chain pharmacy actually makes any real profit on precsription drugs. Drug costs of 100 dollars (and much much more) are not uncommon, and even if the dispensing fee paid was 10 dollars, I don’t believe 10% gross profit (profit before expenses are subtracted) is going to make it profitable. Pharmacy is used as a draw and is viewed as essential to retaileers to be a “one stop shop” for people’s convenience.

    The situation is probably worse than I am stating. I haven’t practiced for over 10 years. My point, however, is, that the chains have to focus on cost cutting, because expenses are high, returns pretty much fixed. So, staff is your greatest expense in most businesses, so it gets minimized.

    That only means one thing – higher workloads, more distractions (fixing people’s insurance problems is a major time eater in the filling process), and therefore higher stress can only mean more mistakes. I am glad to be out of a lousy no win job environment.

  10. sonya
    Reply

    How about using an online pharmacy. Online retailers deal with huge inventories and rarely make a mistake because it is so automated.

    • Kirk
      St Paul MN
      Reply

      Online pharmacies generally charge lower prices, face the same financial pressures from high drug costs and low reimbursements from third party insurance, etc. I have had many mail order errors brought in by people who were more or less forced to use online/mail order prescription services.

      Then there are the added issues of pharmaceuticals being exposed to excessice heat or cold while being shipped long distances, and left in hot mail boxes. Automation in no way reduces risks. A human still has to properly interpret and enter the prescription into a computer, and a human has to load the correct drug (proper strength, proper doseage form) into a counting machine, etc.

      The pharmacist faces the same stresses as a person in retail setting, perhaps to varying degrees, some worse, some better.

  11. Christy
    Frisco, TX
    Reply

    This is genuinely eye-opening. The analogy with bank tellers makes a lot of sense. I personally do not take any prescriptions regularly (I’m 69) and my husband’s are very minimal, but on the rare occasion when I must take something short term, I never think to open the package and check, nor does my husband. I am aware that hospital medication errors are endemic. My husband will be having an aortic valve replaced soon and I intend to have someone in the room as much as possible to examine all meds before they are given.

  12. Bobbie
    NC
    Reply

    I’ve watched our pharmacist in action and looking harried even with a tech to help him. The big box stores that have so much volume but don’t hire enough help. It’s a shame especially since these young men and women are doing a great job coping with it. We’ve not had any problems but I check to make sure everything matches up just because I know the pressure they’re under.

  13. Don
    Texas
    Reply

    As a consumer how do I verify my order is filled correctly?

    • Greg Pharmacy Student
      Toledo, OH
      Reply

      Don,

      Good question. It’s important to know what parts of the prescription human hands touch, so you know where the possibility for human error occurs. The more you take your treatment into your own hands the more you’ll be sure you are getting the right medication and the right care.

      1) The pill description on the bottle should always match the pill in the bottle. Unfortunately this can be hard to see.

      Check for yourself online or with the pharmacist:
      2) What is this medication for – what is it used to treat? Ask yourself if you still have that condition – sometimes doctors forget to stop meds. If you have 2 meds for the same condition sometimes this is ok sometimes you might have unnecessary duplication.

      3) If is a new medication, is this a normal starting strength? Is it the strength dose for kidney or liver function (both decline with age). In elderly people doctors tend to, “start low and go slow” – but sometimes increasing the strength gets forgotten.

      4) What are the common side effects? Some are ok and to be expected, some mean you should switch to a new medication. Listed side-effects do not mean expected side-effects. Ask for the package insert, which lists what percent % of people have the listed side-effect. Is your doctor treating a side-effect? Sometimes treating the side-effect is the best course of action.

      5) Do the benefits of this medication (avoiding hospitalization, increase quality of life) out-weigh the risks (side-effects, cost).

      6) What is the recommended treatment for my condition. For common things like high blood pressure, diabetes, and asthma there are step-wise treatment guides.

    • Ellen
      Reply

      I am a clinical pharmacist with both bachelors and doctoral degrees in pharmacy. I spent the bulk of my career in the pharmaceutical and biotech industries, not having to deal directly with patients. When I retired I took a “retirement” job with a large chain with a phenomenal computer system. At age 72, I believe that I am doing more good for my patients than I ever did developing/researching drugs in industry. I talk with each of them, as our company mandates I do, and IF errors are made, they are caught before they leave the pharmacy. Further, we have many fail-safe processes in place that are designed to catch any errors before they even reach me to check & verify (the tech has to scan bar-coded bottles & if the bar codes do not match they cannot fill the prescription).

      Patients talking to their pharmacist is the most important solution, including confusion on how to take their medication and why they’re taking the medication (lots of things get caught at this step, as the prescribers chose the wrong drug from their “menu” & sent the wrong one in for the patient). They check for two patients with the same name AND the same date of birth (yes, it really does happen but they are on different medications!) and more.

      Patients should ask to discuss their medication with their pharmacist each and every time they get their meds filled or refilled. When patients tell me “I’ve been on this medication for over 30 years,” I always tell them that I’m going to try to tell them something about that medication that they may not know & I do (example – thyroid-dosing changes as a patient ages because of changes in body water/body fat and weight). They are surprised and pleased that they talked to me.

      Pharmacists are THE drug experts. No other professional has the knowledge base of a pharmacist with regard to drugs. Patients & pharmacists need to be communicating. Many problems will be taken care of at that step. And as an FYI, robots (automated filling) does NOT guarantee that no errors will be made. Many stories on that.

  14. Grace
    Reply

    At hospital discharge after a hip replacement, there was a scramble for the pharmacy to fill the last minute anticoagulant prescription to go home with me. Two concentrations of the same med so that I could reduce the dosage after several days. The entire discharge process was rushed, because that was the time all regular patients were being discharged.

    The drug required monitoring of clotting time; my test results did not meet expectations. After two failures, and the nurse direction to “double the number of pills” … I closely examined the two bottles and their contents. Bottom line … the pharmacy tech had apparently done both at the same time, and put them in the wrong bottles. They broke the rule (only do one at a time) because of time pressure and thinking it wasn’t a big deal because they were “the same drug”. This article is “spot on”!

  15. Sami
    SC
    Reply

    I once had a pharmacy give me someone else’s Rx in my bag. I immediately called and told them of THEIR error.

    I returned to pharmacy counter and they gave me a hard time about returning the Rx….”they cannot accept after leaving pharmacy area!!!”

    What!!! You all made the mistake – it is not even my Rx!!! After a lot of back and forth and threatening to call a news agency they reluctantly took it back – no kidding!!

  16. Linda
    Rhode Island
    Reply

    Thanks for a timely and much needed Alarm Bell on a very important topic: did you get the correct medication your doctor ordered from your pharmacist? So many opportunities for human and technical error! Who knew?

    I’m glad to share what I have done for years, simply because I lean on the side of safety-first. After I get my stapled bag at the pick-up counter, I open it right then and there, take out the item and read it for accuracy, including using the same manufacturer (for consistency) and reassure myself that all is correct. It may help to bring the previous empty bottle with you.

    I keep a friendly manner and assume that it is appreciated, smiling and saying, “just to make sure, I hope you don’t mind.” It’s one or two minutes out of everyone’s life and it’s for your well-being, maybe even your life.

    • Greg Pharmacy Student
      Toledo, OH
      Reply

      Linda,

      Many pharmacies do not staple their bags anymore so these type of errors don’t occur. It’s important that you see and verify what you are taking. I wish that the same manufacturer was something I could count on. It seems like the pharmacy staff is not always able to control which manufacturer they carry.

  17. David
    Reply

    Pharmacies are no longer generally owned by caring pharmacists, but rather by bottom line corporations. Numbers are all that matter. Many pharmacist duties are being provided by less educated “pharmacy” techs. Speed means more money for the corporation. Dumbing down the cost of employees means more money for the corporation. Get the picture. America today. Everything is about the $$$.

    • Sara
      North Carolina
      Reply

      David, you are absolutely correct! As it is taught in Accounting, there are only two reasons for businesses to exist: !, to make a profit, and 2, if stockholders are involved, to keep them happy (which includes making a profit)!

  18. J
    Reply

    Large pharmacies and understaffed pharmacies are a disaster waiting to happen. I get concerned when I see the staff looking and acting rushed and overwhelmed.

    • Kirk
      St Paul MN
      Reply

      The worst part is, it’s not a matter of “If”, but when.

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