Pharmacy Error can be deadly

To err is human; to forgive, divine. – Alexander Pope

The phrase sounds perfectly poetic, but when the error occurs at the hands of a pharmacist dispensing the wrong medicine to a patient, it loses all of its charm.

“Most people realize human error can happen, including when getting a prescription filled at the pharmacy,” ConsumerMedSafety.org states in an article titled “What to expect when a pharmacy makes a mistake.” “Although pharmacists do their best, mistakes sometimes happen.”

Mistakes happen can sometimes be accepted. When the professional has accepted the responsibility for patient safety and preservation of life, mistakes can’t happen. That is why procedures exist to prevent those mistakes.

ConsumerMedSafety.org documents the case of a woman prescribed Xanax and received a thyroid drug. While the result was not fatal, it definitely was harmful. Here is how it happened:

“After picking up a refill for alprazolam (Xanax) to treat anxiety, a consumer noticed that the pills were white, not blue as she expected,” ConsumerMedSafety.org states. “She assumed that the pharmacy had switched to a different generic medicine, so she took one tablet as prescribed. Two hours later, she took another tablet because she was still feeling anxious. Several hours later, she called her doctor, who advised her to take two additional tablets. Still feeling anxious, the consumer called the pharmacy after she started shaking, felt cold and jittery, and her mind and heart were racing. The pharmacist asked about the color and markings on the tablets, and then told the consumer that they were a thyroid medicine.”

There are cases that are far worse. According to a HealthDay article titled “Avoiding Pharmacy Errors,” a team of researchers analyzed nearly 10,000 prescriptions dispensed at a New Jersey hospital and found over 1,300 mistakes, which ranged from the wrong medicine to the wrong dose to the wrong label.

“In other words, mistakes were made in roughly one in eight of the prescriptions,” HealthDay states. “Thanks to safer medicine labels and technologies like barcode scanning, mistakes of the past are rapidly declining. The few pharmacy errors that do slip by usually do not cause serious or permanent harm. Still, that’s little consolation to a consumer who is harmed or could have been harmed if a more serious error had happened.”

Here are best practices, tips, etc., patients can take to prevent becoming victims of pharmacy errors:

• Be proactive. Check to see whether the prescription contains the right medicine, the right dose and the right label.
• Ask what the prescription is for, how to take it and how long to take it. Other questions should pertain to what foods and drinks to avoid when taking the medicine and what happens if a dose is missed.

“It’s equally important for you to give your pharmacist all the information he or she needs,” HealthDay states. “Make sure you understand exactly what you’re taking and why, and tell the pharmacist what other drugs or supplements you’re taking.”

Ultimately, it is important for the patient to keep track of his or her prescriptions and be vigilante about what is being dispensed to them.

Other actions to take include:

• Updating personal histories and information, such as name, birthdate and place of residence. Often, patients with similar names get mixed up; that results in each leaving the pharmacy with the other’s prescription.
• Updating allergic reactions. That can enable the pharmacist to know ahead of time whether a prescription will trigger an allergy and stave off the problem by calling the patient’s doctor and finding an alternative medicine.

“Make sure the pharmacy knows about all of the other medications you are taking, and if you have other health conditions,” according to a UC San Diego Health article titled “Over the Counter: Avoiding Errors at the Pharmacy.” “The pharmacy software is designed to cross reference all medications a patient may be taking to assure that there are no drug interactions that could cause the patient harm. The system will also identify if there are contraindications or side effects that would affect the patient. If you tell your pharmacist about all of your over-the-counter and prescription medications, as well as medical history, you can help prevent potentially dangerous side effects.”

For patients who speak another language, a translator should be onsite. If not, a translation service can be used. Language barriers are a big contributor to pharmacy errors.

“A trip to the pharmacy should be routine and painless for patients seeking medical treatment,” UC San Diego Health states. “Following these simple steps will help assure that patients receive the correct medications. If you believe that there was an error in filling a prescription, be sure to ask for a face-to-face with your pharmacist, who will be more than happy to help.”

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