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Pharmacy Mistakes Could Be Deadly

Pharmacy Mistakes Could Be Deadly

The modern pharmacy is big and busy. Hundreds of prescriptions are filled daily in a typical chain drugstore.

Everyone is in a hurry. Pharmacists and technicians work at maximum speed with limited time for lunch or bathroom breaks. Drive-through windows give many drugstores the look and feel of a fast-food restaurant.

Patients behave the same way. They are eager to grab their bag of pills and dash out the door. That could be a prescription for trouble.

One reader described a recent experience: “I opened a new bottle of pills and saw the description written on the label–color of tablet, shape and code. I had seen that before but had not paid much attention to it.

“This time I checked the tablets and discovered that the bottle contained the wrong medicine. The color and shape were right, but the tablets were stamped with the wrong code.

“I returned to the pharmacy, where the pharmacist checked the medicine and said it was indeed the wrong pill. I had been given the correct medicine but one that was four times as strong as my doctor prescribed. As a result, I resolved to check all medicines. Anyone can make a mistake, but I don’t want to suffer the consequences.”

This reader was wise to scrutinize his prescription bottle carefully. Many patients don’t take the time. They just start swallowing pills.

With so many medications now available as generics, the shape and color of pills may not be a reliable guide to whether you have received the correct medicine. Pharmacies frequently change manufacturers, so tablets may have a different appearance from one refill to the next.

Had this reader unwittingly taken the quadruple dose that was dispensed, it is entirely possible that he would have suffered serious side effects.

A visitor to our website reported a different kind of pharmacy error: “About 15 years ago, my son picked up a refill for his seizure medication. He started taking it as usual even though he noticed a minor change in the pill.

“He called me a few days later and said he wasn’t feeling well. I told him to bring his meds so we could look them up in my reference book. Checking the pill in the image section showed that my son had been given a diuretic called Lasix in place of the 3-times-a-day anticonvulsant medication he should have been taking.

“I rushed him to the emergency department, where they gave him IV potassium. The doctor told me if my son had let this go another 24 hours, his heart would have stopped and my son would have died.

“I now always check any new meds online. We have to be our own best advocate.”

This important point is underscored by research showing that dispensing errors are common in hospitals and nursing homes as well as in community drugstores (Journal of the American Pharmacists Association, March-April, 2009).

To protect yourself or someone you love from such mistakes, check our top 10 tips on escaping pharmacy errors. You’ll find them in our book, Top Screwups Doctors Make and How to Avoid Them, available in libraries, bookstores and online at www.PeoplesPharmacy.com.

Because millions of mistakes occur every year, nobody can afford to be complacent about double-checking prescription medicines.

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About the Author
Terry Graedon, PhD, is a medical anthropologist and co-host of The People’s Pharmacy radio show, co-author of The People’s Pharmacy syndicated newspaper columns and numerous books, and co-founder of The People’s Pharmacy website. Terry taught in the Duke University School of Nursing and was an adjunct assistant professor in the Department of Anthropology. She is a Fellow of the Society of Applied Anthropology. Terry is one of the country's leading authorities on the science behind folk remedies. .
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