Pharmacists used to be one the of most respected group of professionals in America. That was back when there were lots of independent drug stores and the pharmacist knew your name and actually talked to you. Now, most pharmacists are sequestered behind a computer. Your interactions are primarily with a technician. Pharmacies are very busy places. Too often pharmacists have to fill so many prescriptions so fast that mistakes in the pharmacy have become common.
What Happened to the Neighborhood Pharmacy?
The small town where we once lived had a family-owned pharmacy. It was literally a mom and pop operation. Benny was the pharmacist and Sarah, his wife, operated the cash register.
You always handed your prescription directly to Benny and discussed what it was for. He could usually fill it within minutes because there weren’t that many people in the drugstore at any given time.
Benny knew most of his customers by name. If there were special instructions, he reviewed them carefully. He also made sure you understood the pros and cons of the medicine and how to take it correctly.
Even before that, my grandfather Joe was a compounding pharmacist in New York City. I have his scale and glass measuring beaker. He used them for creating tailor-made medicines for the patients who came into the pharmacy.
The Big-Box High-Tech Drugstore:
Today’s modern chain drugstore is quite different. You rarely speak directly with a pharmacist. Your physician will probably submit your prescription electronically. In the unlikely event you do get a paper prescription, chances are good that you will hand it to a technician, not a pharmacist.
When it comes time to pick up your prescription, the tech who hands you your prescription and takes your money can’t answer your questions about the medicine. If you want to talk to the pharmacist, you have to make a special request and often wait for her to emerge from behind a computer screen somewhere in the back.
A Patient Offers Suggestions to Avoid Mistakes in the Pharmacy:
Q. You have written about pharmacy errors, but you did not emphasize that this is a potentially life-threatening issue. There are two resources that could help.
First, many patient leaflets have the physical description of the pills. I check each refill against the leaflets to verify the name of the drug, the color, size, shape and the identifying codes. Second, several websites give detailed physical descriptions or photos of pills.
I worked in health insurance. My pharmacist friends never take any medication without checking it. When my parents were hospitalized, I asked about everything that came in the room.
Since scripts usually go straight to the pharmacy via computer, a lot of people might not pay attention to what is being prescribed until they pick it up. Patients and their families need to be proactive to avoid mistakes in the pharmacy.
A. Thank you for the reminder that everyone should be aware of what medicine they are prescribed and that they should always check it before leaving the pharmacy counter.
One reader recently reported:
“I have Crohn’s disease and take 0.6 ml opium tincture for diarrhea. I recently renewed my prescription, and when I got home, my daughter read the label out loud.
“When she said 6 ml, I grabbed the bottle and called the pharmacy. They were horrified. They apologized over and over, refunded my cost, gave me a proper label and thanked me for catching their mistake. We both knew that taking 6 ml of opium tincture could put a person in a coma.”
This underscores the importance of checking each detail of every prescription. We have written more extensively about pharmacy errors in our book, Top Screwups. You can find it in the book section of the store at www.PeoplesPharmacy.com. This book provides practical tips on how to avoid pharmacy and medical mistakes.
Pharmacists Worry About Mistakes in the Pharmacy!
The high-pressure productivity-oriented atmosphere of big box stores makes many pharmacists unhappy.
We recently heard from one.
“I hope you will print this letter as a way to increase patient safety. In the last several years, even before COVID, the average pharmacy has become so busy that the pace at which the pharmacist and the staff must operate creates a workplace in which an error is likely to occur.
“The Boards of Pharmacy in both Ohio and Missouri have surveyed pharmacists in their states. Half of the respondents said they work in an environment in which they are not able to do their job safely and effectively. During this time, the major pharmacy chains, in order to increase profits, have cut staffing levels, causing this unsafe increase in workload.
“This is what I want the public to know and here is the action I would like the public to take:
- Notice if your pharmacy is too busy!
- Are there lines to drop off or pick up a prescription?
- Does it take a long time for the prescription to be filled while you wait?
- If you call the pharmacy, are you placed on hold for a long time, or is the phone not answered at all?
“If you experience any of these, ask the pharmacist if there is enough staffing for the pharmacy to be safe. If the answer is no, then please contact your state Board of Pharmacy and inform it that the staffing situation needs to be investigated.
“The reason I am asking the public to call the Board of Pharmacy is because I myself have brought these concerns to upper management where I work. Their response has been that there is no staffing problem. Sometimes they tell me to stop whining and complaining. They have also threatened me with termination for bringing up a safety concern.
“They may not listen to me, but the pharmacy chains must listen to the Board of Pharmacy, because this is where they get their license to operate. Please make your state Board of Pharmacy aware. I do not want to mistakenly give someone the wrong medication.”
This pharmacist’s concerns are valid.
A Patient Describes a Pharmacy Mistake:
Q. I was at the receiving end of a pharmacy mistake. My sleeping pills were replaced with Adderall. When I asked why they looked different, the pharmacist said they had a new manufacturer.
Days later, I called to complain that the new pills didn’t work, and the pharmacy blew me off. I finally went back to the store to complain, tweaking on Adderall and no sleep. The pharmacist accused me of drug seeking. After pulling my records, they realized their mistake. The pharmacist offered no apology, nothing.
I’m going to report the drugstore to the board of pharmacy and make a call to the DEA. After all, they gave me Adderall, which is supposed to be a controlled substance. They either fudged their daily count or were just too careless. Either way, they need to be called to account. Had a simple and sincere apology been offered, I would have accepted it and moved on. It wasn’t.
A. We are sorry that you experienced such a serious pharmacy error. Taking a stimulant containing amphetamines instead of the prescribed sleeping pill would be counterproductive, to put it mildly.
Pharmacy errors are more common than most people imagine. Although technology has reduced the frequency with which wrong drugs are dispensed, it still happens too often (Journal of the American Pharmacists Association, Sept-Oct. 2020).
Everyone should check their prescription before leaving the pharmacy counter. If something doesn’t look right, ask the pharmacist to double-check immediately.
Many people don’t realize that they could file a complaint with their state board of pharmacy if they have evidence of a violation on the part of a pharmacy. The board will not resolve customer service issues or elicit an apology or financial settlement, but it should investigate an error report.
Tragic Mistakes in the Pharmacy:
The journal Pharmacy Times (May 18, 2022) describes a series of errors that led to a patient’s death:
“A pharmacist erred in recording medication use instructions on the label of a dispensed prescription and the error was not spotted by 2 other pharmacists issuing refills.
“A cardiologist in a Midwest state issued a prescription requesting dispensing of amiodarone for a male patient who had chronic ischemic heart disease and atrial fibrillation. The pharmacist initially dispensing the medication made an incomplete recording of the medication use directions on the container label. The instructions that the cardiologist gave to the pharmacist for reproduction on the label were: two 200-mg tablets twice a day for 1 week, then one 200-mg tablet 3 times a day for 2 weeks, then one 200-mg tablet twice per day for 2 weeks and then one 200-mg tablet daily.”
Instead, the pharmacist left off the last part of the instructions. Instead of getting about 20 weeks of amiodarone at a tapered dose, the patient received twice the prescribed dose “for a protracted period.”
“The patient’s health deteriorated during the remainder of that year and he ‘suffered mightily in the weeks before his death’…”
A Pharmacy Tech Spills the Beans:
Q. I worked as a certified pharmacy technician for 14 years. It was frightening how many times we received prescriptions from doctors that were for the wrong dose, the wrong medication, even the wrong patient. Fortunately, our pharmacists called the doctor if there was any doubt or question. They probably saved many lives.
A. Thank you for sharing this scary story. For years, pharmacists had to decipher doctors’ handwritten prescriptions. Illegible writing contributed to serious dispensing errors.
Now, electronic prescribing is supposed to eliminate those kinds of mistakes. But computers introduce other types of problems. E-prescribing can make it possible for physicians to choose the wrong drug, patient or pharmacy from the drop-down menu (Integrated Pharmacy Research and Practice, May 20, 2015). Incorrect directions may carry over from previous prescriptions. Sometimes e-prescriptions don’t specify the dose or frequency correctly.
Call Back? Good Luck!
The tech who shared this insider’s perspective stated that the pharmacists “called the doctor if there was any doubt or question.” The problem is that getting through to a busy physician is not easy. Pharmacists have confessed to us that the receptionist often says something along the lines of “doctor is seeing patients now. She will call you back later.”
The call back can take hours or even days. Meanwhile, there is a patient waiting to get a prescription. Pharmacists confide to us that many calls are never returned. Some physicians get mad if a pharmacist questions a dose or a drug interaction.
Alert Fatigue: The Cry Wolf Phenomenon:
Alert fatigue is another source of potential trouble. Both physicians and pharmacists can become overwhelmed by numerous computerized red flags warning of potential drug interactions or adverse reactions. This “cry wolf” phenomenon can lead even a conscientious health professional to ignore important cautions.
That’s why patients need to double-check their prescriptions. After all, they are the ones who will pay the price if someone makes a mistake. To assist them, we have written several chapters about how to avoid prescribing and dispensing errors in our book, Top Screwups. It can be found in the books section of the store.
Why Don’t Pharmacists Study Mistakes in the Pharmacy?
We have always been impressed with physician researchers who study medical errors. If you search the National Library of Medicine (PubMed) and put the phrase “medical mistakes” in your the search box, you get more than 160,000 citations. If you put “pharmacy mistakes” in the search box you get 323 citations.
That gives you some idea of the priority that the profession puts on monitoring mistakes in the pharmacy. The few studies that have been done suggest that pharmacy errors are relatively common, between 1.4 and 1.8 percent of all prescriptions (BMJ Open Quality, Oct. 2, 2018).
One review found that the wrong drug is dispensed once in every thousand prescriptions. That may not sound bad, but with 4.22 billion prescriptions dispensed, the result is 422,000 people getting the wrong medicine. Experts estimate that a quarter of a million Americans are harmed every year as a result (Journal of the American Pharmacists Association, Sept-Oct, 2020).
The authors of this study conclude:
“This analysis found that wrong drug dispensing errors were also common because of failures to take extra steps to verify the prescription, including checking the drug dispensed against the label and the prescription, reviewing the prescription with the patient, and using indication-based prescribing.”
This is why patients must be more proactive whenever they pick up a prescription in a pharmacy or take a box containing medicine out of the mailbox! Here is a reader who discovered a pharmacy error almost by accident:
Why You Shouldn’t “Grab & Go”:
“I would like to chime in here about a medication mistake that happened with one of my prescriptions years ago. I went to a large chain pharmacy to pick up my prescription and did the ‘grab and go.’
“The bag had my paperwork on it, so I didn’t bother to check to make sure that the correct medication was in the bag. I got home and started to merge the medication I had left into the bottle that I had just picked up. That was my habit at the time.
“Oops! I immediately realized that the medications didn’t match. I checked the new bottle and found it had someone else’s name on it, along with a different medication that I had never heard of. I checked the paperwork a second time to make sure that it had my name on it. Yes – it was just that someone else’s medication ended up in my bag!
“I headed back to the pharmacy with the bag of medication and receipts. When I arrived, the pharmacy was quite busy. A pharmacist asked if she could help me and I told her that she had given me the wrong medication. She responded that no such thing could’ve happened. I’m sure she wanted to get rid of me because of all of the customers waiting in the pharmacy area. I insisted that a mistake had been made. Finally, just to shut me up, she agreed to check the bag.
“Well – the color drained from her face when she did. She saw that indeed I had been given a bag with my paperwork attached but someone else’s medication bottle in it. She rushed to the bins and checked to see if a bag with the other patient’s paperwork was still in the bin. It was. Thankfully, my medication bottle was in the other person’s bag. She swapped them into the correct bags and handed me the bag with my name on it. (I verified that I had the correct bottle before leaving).
“I’m glad I was paying attention and realized the medication I had been given wasn’t right. I’ve periodically wondered what might’ve happened had I not been vigilant. If we took each other’s medication, what damage could’ve happened?
“I understand that the pharmacist is human. She didn’t want to admit to making a mistake. I’m sure she didn’t want to scare other customers and have them thinking they might get the wrong medication, too.”
The BIG Oops: Beware Mistakes in the Pharmacy
We would all like to imagine that pharmacies are error-free zones. In truth, however, mistakes in the pharmacy are shockingly common. Although we described a relatively low rate of mistakes above (1.4% to 1.8%), one study revealed a dispensing error rate “of more than one in five prescriptions” (Journal of the American Pharmacists Association, March-April, 2009).
Although most are relatively minor, some have led to disability and even death.
Tragic Story:
Here is a story from the Houston Chronicle dated January 7, 2016. According to a lawsuit, an older woman went to a pharmacy to fill a prescription for an antihistamine called hydroxyzine (75 mg). It was allegedly filled with a diuretic called hydrochlorothizaide (HCTZ), a drug for high blood pressure.
The article notes that this drug would normally be prescribed in a lower dose, such as 25 mg. The newspaper article reported that after the woman took the HCTZ, she:
“…lost blood pressure, suffered kidney failure and was hospitalized on life support until her death on Dec. 14.”
In his new book, The Shocking Truth About Pharmacy: A Pharmacist Reveals All The Disturbing Secrets, Dennis Miller, R.Ph. writes:
“Due to understaffing, simple carelessness, look-alike / sound-alike drug names, poor handwriting, and other factors, we mistakenly grab the wrong drug far more often than you believe.
“Pharmacies use technicians because it is much less expensive to hire techs than it is to hire additional pharmacists. These technicians vary in ability from those that are super-competent to those that are an accident waiting to happen.”
“Some pharmacy chains have a red light on the computer screen which alerts the pharmacist that it has taken a long time to fill a prescription once it has been entered into the system. Pharmacists derisively refer to this as ‘racing the red light.’ I did not work for a chain that had such a red light, but I am told that pharmacists would be admonished by their district supervisors when the red light frequency became excessive.”
You can buy the Kindle edition of the 394-page-book, The Shocking Truth About Pharmacy, for $0.99 on Amazon at this link.
Protect Yourself and Those You Love
You can learn more about how to protect yourself from pharmacy errors and dangerous drug interactions in our book, Top Screwups Doctors Make and How to Avoid Them (PeoplesPharmacy.com). We have a section on the “Top 10 Screwups Pharmacists Make.” Here is our list:
- Not counseling patients
- Dispensing the wrong drug
- Dispensing the wrong dose
- Ignoring interactions
- Not standing up to doctors
- Trusting all generic drugs
- Relying on inadequate labels and leaflets
- Not reporting errors
- Switching drugs without patient approval
- Not supervising techs carefully
Learn how to protect yourself from each problem in Top Screwups.
We think staffing and working conditions are critically important. It may be unrealistic to expect a pharmacist to admit that there are staffing shortages in any given store. If you suspect that is the case, however, it does make sense to alert the Board of Pharmacy in your state.
Share your own pharmacy experience in the comment section below.
