Deadly Prescription Mistakes Made by Pharmacists

If you think all the people in white coats behind your pharmacy counter are actually pharmacists, you are in for a big surprise. Some may actually be high school students, with very little experience or training in the field of medicine. In many states, these technicians are allowed to access the medication stock shelves, and fill prescriptions. They can also check with doctors to authorize refills, and enter drug information into the computer. It's a scary thought indeed, and it may be one of the reasons so many pharmacy errors are occurring.

Sometimes prescription drugs appear almost identical, and incorrect drugs are given by mistake. This was the case in the tragic incident that happened to little four month old Alexandra Gehrke. Born premature, Alexandra needed Phenobarbital to prevent seizures. Instead, she was given an adult diabetes medicine that resembled her prescription. A busy pharmacist did not notice that the number and brand on the pills signified that they were not Phenobarbital. As a result, the incorrect medicine was given to the baby for seven days. It caused seizures, and left her with brain damage that will last a lifetime. She cannot talk, walk or feed herself. The jury in the court case found Walgreens at fault, and awarded the family 21 million dollars, but the pharmacist responsible for the error still works at a nearby Walgreens, and is the pharmacy manager.

The television show 20/20 did a four month investigation of pharmacy errors. Time and time again, they observed many pharmacy technicians filling prescriptions. This is legal in many states, with the understanding that the pharmacist will recheck each prescription. But that did not protect Beth Hippely, a mother of three from Lakeland, Florida. She was prescribed the blood thinner, Coumadin, after she started chemotherapy for a treatable breast cancer. But a pharmacy technician, a high school student at the time, typed on Beth's prescription label a dosage 10 times more than her doctor prescribed. She suffered a stroke that left her brain damaged and disabled. As a result, she was unable to continue chemotherapy, and died when her cancer returned. The pharmacist was unaware of the mistake, until called to testify in the court case. She has recently been promoted.

Unfortunately, there are many such cases. According to the Institute of Medicine, medication errors harm at least 1.5 million people every year. The Food and Drug Administration has reported that medication mistakes cause at least one death per day. Only a few states require pharmacies to report serious mistakes that result in extreme injury or death, and there are no federal requirements. State pharmacy boards report that overworked, tired pharmacists are making more mistakes than ever. Many pharmacists work 12 hour shifts, and 60 hour work weeks. There is a greater demand for prescription drugs. The paperwork for dispensing drugs is more complicated than ever, and insurance requirements result in greater delays in getting medicine to the consumer. Pharmacists are often pressured to turn out prescriptions at a very fast pace. Many patients take multiple drugs. Pharmacists have so much to be aware of, including age restrictions, maximum daily dosages, drug interactions, possible allergic reactions, and disease interactions. In addition, they must make sure that the amount of medication is appropriate, that the label is correct, and that the medication is the right one. (Many pills are similar in color and shape, while others have names that are almost identical.) All pharmacists must also deal with the age old problem of illegible handwriting by the prescribing physician. Because of the growing problems with errors, many pharmacies have gone to an automated system that alerts the pharmacist to various concerns.

Many state laws require a pharmacist to counsel a patient when they receive first time prescriptions. They must provide information concerning any drug interactions that may occur, as well as potential problems, such as side effects. This is mandatory unless the customer declines instruction.

David Phillips, a sociology professor at the University of California-San Diego, has reported research that indicates the fatality rate for medication errors increases by as much as 25 per cent above normal at the beginning of the month. This is due to people receiving their Social Security checks at this time. Crowds of people turn up to get their prescriptions filled, and the pharmacists are overwhelmed with work, and consequently make more errors.

While writing this article, I had several of my own prescriptions filled. As I went to place the medications in my cabinet, I decided that in view of what I had learned from writing this article, I had better check to see if they were correct. As I examined and counted my pills, I realized that I had been given a blood pressure pill that was 1/4 of the dose that I had previously taken. The prescription said 2.5 milligrams, when it should have been 10 milligrams. Not taking enough blood pressure medication could be very dangerous to my health. Also, if my blood pressure was still too high by my next check up, the doctor (unaware of the pharmacy's mistake) could have prescribed a higher dosage than I was previously taking, which could also have very serious adverse effects.

Patients need to take precautions to protect themselves. It is important to get the name, dosage and instructions for every drug you are prescribed before leaving your doctor's office. Long gone are the days when ignorance was bliss. When you pick up the prescription, take the time to evaluate the label. Compare it with the instructions you were given by the doctor. Is it the correct medication in the correct amount? Are the instructions the same as those given by the prescribing physician? It is probably a good idea these days to check a new prescription online, and make sure that the pill looks like the correct drug. There are many sites that give a photo of each medicine, documenting color, size and milligrams. When picking up refills, make sure they are identical to your previous pills. Is the shape, color, manufacturer, and number the same? If not, contact your pharmacist immediately for an explanation. Unfortunately, generic drugs are more difficult to identify online because they come from more than one manufacturer. Never be embarrassed to ask questions. As so many have tragically found, it could be a matter of life and death.

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