A patient diagnosed with thyroid problems filled a prescription for the drug levothyroxine. It was written by the doctor for 75 micrograms. It was dispensed at 25 micrograms. Months went by before the mistake was noticed.
“Since this started, my hair has been brittle and falling out, my skin has been thinning and slow to heal, and I’ve experienced muscle and weight loss and sleep disturbances,” the patient asked The People’s Pharmacy in an article in The Atlanta Journal-Constitution titled “Pharmacy error caused months of misery.” “Do I have any recourse besides letting you know that others should check all their prescriptions carefully? I am happy to have survived this nightmare.”
Another patient was not so lucky and received a dosage too high and resulted in death. The drug Coumadin, a powerful blood thinner, was dispensed at 10 times the amount prescribed, leading the patient to suffer a brain bleed that caused a brain injury that made talking and walking nearly impossible.
“You probably think that a pharmacist fills your prescription when you bring it into your pharmacy,” wrote Searcy Denney Scarola Barnhart & Shipley partner Karen Terry in a blog titled “Pharmacy technicians fill patient prescriptions, but are not required to have any special education.” “That’s not the case. The actual person filling your prescription is the pharmacy technician. Pharmacy technicians are essentially assistants or helpers to the pharmacists. Pharmacy technicians are not required to have any education at all. They simply must be 16 years of age in Florida to qualify to fill prescriptions in a pharmacy.”
The pharmacy technician who filled the Coumadin prescription was an 18-year-old high-school student with no training.
“So how does the pharmacy justify using young, untrained employees?” Attorney Terry wrote. “The conclusion is inescapable: trained pharmacists cost more than young technicians and it permits an environment in which more prescriptions can be filled faster and pharmacies can make more money.”
Such horror stories occur all too often, putting patients at serious risk when they think they are following doctor’s orders to try to get better. Errors like the ones above are one of the leading causes of mortality across the country. Dispensing errors, specifically, make up nearly one-quarter of the many other medication errors that occur and, sadly, are preventable. They include incorrect directions and / or instructions printed on the label and / or the bag, failure to realize a contraindication or an adverse drug reaction and / or allergy based on what other drugs the patient is taking and, worst of all, illegibility that leads to assumption.
“Pharmacists’ “second guessing” of illegible and / or ambiguous prescriptions, nonstandard abbreviations, acronyms, decimals, and call-in prescriptions are frequently associated with medication errors,” Pharmacy Times states in an article titled “10 Strategies for Minimizing Dispensing Errors.” “Whenever in question, it is important to call the prescriber to clarify any uncertainties or doubts regarding the prescription. Clarification obtained from the physician should be promptly documented. All verbal prescriptions should be immediately transcribed to a blank prescription pad and read back to the caller to ensure that the prescription has been transcribed correctly.”
It is estimated that pharmacy errors occur at least four times daily in a drug store that fills 250 or more prescriptions daily, translating into an annual 51½ million mistakes nationwide.
“In addition to causing serious morbidity and mortality, dispensing errors increase the economic burden on society by adding to health care costs,” according to Pharmacy Times. “Faulty dispensing may also result in litigation, which can be expensive and lead to increased costs for professional liability insurance coverage. Dispensing in error is traumatic for the pharmacist as well as the patient; therefore, the goal of every pharmacy is to reduce the amount of dispensing errors.”
The National Center for Biotechnology Information, part of the National Institutes of Health, concluded in a study titled “Prescribing errors and other problems reported by community pharmacists” that pharmacy errors might be mitigated going forward “by improving communication and sharing of information between GPs and pharmacists and by making changes to the design of computerized prescribing systems.” Still patients would be well-advised to realize the dangers of pharmacy errors and take a proactive, responsible approach for checking their prescriptions for accuracy.
“Don’t ask, don’t tell” is never a smart policy when it comes to medications and your health,” states a Mayo Clinic article titled “Medication errors: Cut your risk with these tips.” “Don’t hesitate to ask questions or to tell your health care providers if anything seems amiss. Remember, you’re the final line of defense against medication errors.”