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Prescription Errors: The Saga Continues With Children Receiving Cancer Drug In Error


I have written previously regarding the hidden epidemic of prescription errors. For every error that makes the news I am certain there are thousands that go unreported.

The most recent report of a potentially disastrous pharmacy error is reported by ABC news and involves a child receiving Tamoxifen, a very potent breast cancer fighting drug, instead of fluoride, a simple vitamin to enhance dental health. This type of an error is simply inexcusable.

The known, serious side effects of Tamoxifen are many and include:

  • blood clots
  • strokes
  • uterine cancer
  • endometrial cancer
  • cataracts

No child should be exposed to this type of preventable error. In CVS’s statement once again they ascribe this occurrence to:

“Prescription errors are a rare occurrence, however since any process involving people is not immune from the possibility of human error; we are committed to continually improving quality measures to help ensure that prescriptions are dispensed safely and accurately.”

If that is the case, we have a ready illustration that pharmacy consumers are those who will suffer from human error causing incorrectly filled prescriptions. Isn’t the real question about what can or should be done to further limit, if not eliminate, these dangers?

Perhaps one of the answers is to provide reliable information, which consumers can use in evaluating where they want to go to fill prescriptions. Why not have pharmacies actually post their statistics identifying the frequency and types of errors right there at the pharmacy counters for all their customers to see? Yeah, I don’t see that happening either.

CVS did conduct an “investigation” to determine if any other children were affected. It is a little unnerving that CVS indicates “most of the families we have spoken to did not indicate that their children received any incorrect pills.”

Well, that warms my heart that “most” of them didn’t get cancer fighting drugs instead of fluoride for their little teeth. Maybe that’s the catchy new slogan: “At CVS we mostly get it right….well, a lot of the time anyway.”

My concern is that, in the cases in which I have been involved, the pharmacy’s excuse in prescription miss-fill cases is this same old song and dance: mistakes were made… but we are real sorry; or some variation on that message.

I have never been involved in a case where it is admitted that a key causal factor is the volume of prescriptions being filled. And the pharmacy corporation will fight all efforts to discover that they are regularly understaffed or employing undertrained personnel. These causal factors are a critical part of the problem when negligence occurs in pharmacies.

Every corporation has safety systems in place; responsible corporations demonstrate real concern when those systems do not seem to be handling safety. Too often human error is used as an excuse in lieu of really looking in the mirror and trying to weigh the profit motive to grow fast, and fill faster, against consumer safety.

Don’t take my word it, though; ask any of the honorable employees in the pharmacy industry trying to keep up the pace. They will tell a story that, quite often, dictates profit over safety.

Listen I wasn’t there, but when CVS in its public statement only lists something like keeping similar looking medication away from each other, it tells me all I need to know. Why not simply add to that they will look at the staffing and volume of the store too? Sergeant Schultz from Hogans’ Heroes never stopped, or figured out, a prisoner escape either, and we all know why……he knew nothing!

CVS Caremark released a statement to ABC News that can be found here.

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