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Mistakes in the Pharmacy Could be Deadly

Mistakes in the pharmacy are shockingly common. No other profession could get away with so many errors and remain respected. How can you protect yourself?
Mistakes in the Pharmacy Could be Deadly

Pharmacists used to be one the of most respected group of professionals in America. That was back when there were lots of independent drug stores and the pharmacist knew your name and actually talked to you. Now, most pharmacists are sequestered behind a computer. Your interactions are with a technician. Pharmacies are busy places, even during the pandemic. Too often pharmacists have to fill so many prescriptions so fast that mistakes in the pharmacy have become common. It is more important than ever to make sure that what you get is what the doctor intended!

A Pharmacy Tech Spills the Beans:

Q. I worked as a certified pharmacy technician for 14 years. It was frightening how many times we received prescriptions from doctors that were for the wrong dose, the wrong medication, even the wrong patient. Fortunately, our pharmacists called the doctor if there was any doubt or question. They probably saved many lives.

A. Thank you for sharing this scary story. For years, pharmacists had to decipher doctors’ handwritten prescriptions. Illegible writing contributed to serious dispensing errors.

Now, electronic prescribing is supposed to eliminate those kinds of mistakes. But computers introduce other types of problems. E-prescribing can make it possible for physicians to choose the wrong drug, patient or pharmacy from the drop-down menu (Integrated Pharmacy Research and Practice, May 20, 2015).  Incorrect directions may carry over from previous prescriptions. Sometimes e-prescriptions don’t specify the dose or frequency correctly.

Call Back? Good Luck!

The tech who shared this insider’s perspective stated that the pharmacists “called the doctor if there was any doubt or question.” The problem is that getting through to a busy physician is not easy. Pharmacists have confessed to us that the receptionist often says something along the lines of “doctor is seeing patients now. She will call you back later.” 

The call back can take hours or even days. Meanwhile, there is a patient waiting to get a prescription. Some pharmacists confide that many calls are never returned. Some physicians get mad if a pharmacist questions a dose or a drug interaction.

Alert Fatigue: The Cry Wolf Phenomenon:

Alert fatigue is another source of potential trouble. Both physicians and pharmacists can become overwhelmed by numerous computerized red flags warning of potential drug interactions or adverse reactions. This “cry wolf” phenomenon can lead even a conscientious health professional to ignore important cautions.

That’s why patients need to double-check their prescriptions. After all, they are the ones who will pay the price if someone makes a mistake. To assist them, we have written several chapters about how to avoid prescribing and dispensing errors in our book, Top Screwups. It can be found in the books section of the store.

Why Don’t Pharmacists Study Mistakes in the Pharmacy?

We have always been impressed with physician researchers who study medical errors. If you search the National Library of Medicine (PubMed) and put the phrase “medical mistakes” in your the search box, you get more than 150,000 citations. If you put “pharmacy mistakes” in the search box you get 283 citations

That gives you some idea of the priority that the profession puts on monitoring mistakes in the pharmacy. The few studies that have been done suggest that pharmacy errors are relatively common, between 1.4 and 1.8 percent of all prescriptions (BMJ Open Quality, Oct. 2, 2018). 

One review found that the wrong drug is dispensed once in every thousand prescriptions. That may not sound bad, but with 4.22 billion prescriptions dispensed, the result is 422,000 people getting the wrong medicine. Experts estimate that a quarter of a million Americans are harmed every year as a result (Journal of the American Pharmacists Association, Sept-Oct, 2020). 

The authors of this study conclude:

“This analysis found that wrong drug dispensing errors were also common because of failures to take extra steps to verify the prescription, including checking the drug dispensed against the label and the prescription, reviewing the prescription with the patient, and using indication-based prescribing.”

This is why patients must be more proactive whenever they pick up a prescription in a pharmacy or take a box containing medicine out of the mailbox! Here is a reader who discovered a pharmacy error almost by accident: 

Why You Shouldn’t “Grab & Go”:

“I would like to chime in here about a medication mistake that happened with one of my prescriptions years ago. I went to a large chain pharmacy to pick up my prescription and did the ‘grab and go.’

“The bag had my paperwork on it, so I didn’t bother to check to make sure that the correct medication was in the bag. I got home and started to merge the medication I had left into the bottle that I had just picked up. That was my habit at the time.

“Oops! I immediately realized that the medications didn’t match. I checked the new bottle and found it had someone else’s name on it, along with a different medication that I had never heard of. I checked the paperwork a second time to make sure that it had my name on it. Yes – it was just that someone else’s medication ended up in my bag!

“I headed back to the pharmacy with the bag of medication and receipts. When I arrived, the pharmacy was quite busy. A pharmacist asked if she could help me and I told her that she had given me the wrong medication. She responded that no such thing could’ve happened. I’m sure she wanted to get rid of me because of all of the customers waiting in the pharmacy area. I insisted that a mistake had been made. Finally, just to shut me up, she agreed to check the bag.

“Well – the color drained from her face when she did. She saw that indeed I had been given a bag with my paperwork attached but someone else’s medication bottle in it. She rushed to the bins and checked to see if a bag with the other patient’s paperwork was still in the bin. It was. Thankfully, my medication bottle was in the other person’s bag. She swapped them into the correct bags and handed me the bag with my name on it. (I verified that I had the correct bottle before leaving).

“I’m glad I was paying attention and realized the medication I had been given wasn’t right. I’ve periodically wondered what might’ve happened had I not been vigilant. If we took each other’s medication, what damage could’ve happened?

“I understand that the pharmacist is human. She didn’t want to admit to making a mistake. I’m sure she didn’t want to scare other customers and have them thinking they might get the wrong medication, too.”

The BIG Oops: Beware Mistakes in the Pharmacy

We would all like to imagine that pharmacies are error-free zones. In truth, however, mistakes in the pharmacy are shockingly common. Although we described a relatively low rate of mistakes above (1.4% to 1.8%), one study revealed a dispensing error rate “of more than one in five prescriptions” (Journal of the American Pharmacists Association, March-April, 2009).

Although most are relatively minor, some have led to disability and even death.

Tragic Story:

Here is a story from the Houston Chronicle dated January 7, 2016. According to a lawsuit, an older woman went to a pharmacy to fill a prescription for an antihistamine called hydroxyzine (75 mg). It was allegedly filled with a diuretic called hydrochlorothizaide (HCTZ), a drug for high blood pressure.

The article notes that this drug would normally be prescribed in a lower dose, such as 25 mg. The newspaper article reported that after the woman took the HCTZ, she:

 “…lost blood pressure, suffered kidney failure and was hospitalized on life support until her death on Dec. 14.”

In his new book, The Shocking Truth About Pharmacy: A Pharmacist Reveals All The Disturbing Secrets, Dennis Miller, R.Ph. writes:

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

“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.”

You can buy the Kindle edition of the 394-page-book, The Shocking Truth About Pharmacy, for $0.99 on Amazon at this link

Protect Yourself and Those You Love

You can learn more about how to protect yourself from pharmacy errors and dangerous drug interactions in our book, Top Screwups Doctors Make and How to Avoid Them (PeoplesPharmacy.com). We have a section on the “Top 10 Screwups Pharmacists Make.” Here is our list:

  1.  Not counseling patients
  2. Dispensing the wrong drug
  3.  Dispensing the wrong dose
  4.  Ignoring interactions
  5.  Not standing up to doctors
  6.  Trusting all generic drugs
  7.  Relying on inadequate labels and leaflets
  8.  Not reporting errors
  9.  Switching drugs without patient approval
  10.  Not supervising techs carefully

Learn how to protect yourself from each problem in Top Screwups.

Share your own pharmacy experience in the comment section below.

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About the Author
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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