Pharmacy Errors Can Be Deadly

Pharmacists are on the front line for patient safety. They provide a safety net for medication mistakes. Very often they save lives when a prescriber makes an error. Here’s one example a pharmacist offered:
“One evening last week just before closing, an office receptionist called in a prescription. The patient is the spouse of a friend of mine, so I knew who it was. The receptionist started with ‘Lamictal 2.5 mg…’
“I immediately stopped her and said, ‘That patient is NOT on Lamictal [an anticonvulsant].’ I insisted she take another look at the chart. She giggled, ‘Oh, I guess it’s Lomotil 2.5 mg’ [antidiarrheal medicine]. This mistake by the receptionist could have caused great harm.
“Lamictal is available as a 25 mg tablet, so a float pharmacist who might have been working when this was called in: 1) Wouldn’t know the patient; 2) Might think that the receptionist just missed the decimal point (2.5 mg vs. 25 mg), a common mistake; 3) Might just go ahead and dispense it. VERY scary.
“Only emergency prescriptions should be called in; otherwise, there is just too much opportunity for error. All the rest should be e-scribed or written out so the patient has hard copy. Receptionists have no business calling in prescriptions. Such a call interrupts the pharmacist, creating a distraction that could lead to an error on a different task. This particular call created a very dangerous situation. Only because I knew the patient was a possible tragedy avoided.”
Stories like this have us convinced that pharmacists can be heroes. But they don’t catch everything that goes wrong.
One hospital pharmacist shared his frustration: “I am continually shocked and appalled by the number of errors I see. It’s surprising that I am one of the few people offended by this. Most seem to think it par for the course.
“I am not surprised that the reported rate of errors is low. At my hospital a mistake has to be really serious to be sent to the quality committee. And lawsuits just seem to be considered the cost of doing business these days.
“Recently, four of twelve patients in our ICU were there NOT for a problem they had initially, but for complications of treatment. Health care administrators should realize that all the technology in the world won’t prevent errors due to chronic understaffing. Nurses come up with ingenious ways to bypass barcode scanning and other safety measures just because they are always short-staffed, as we are in the pharmacy.”
Pharmacists are highly trained health professionals. They can save lives if given the chance. When mistakes occur, though, the results can be tragic, as one reader reported:
“My ex-husband died from a pharmacy error. He was in relatively good health before the pharmacy dispensed an overdose of Coumadin. The physician denied any responsibility for this problem, though the pharmacy blames the physician.
“The drug manufacturer clearly states in its written information that Coumadin should not be taken twice a day. Even if the physician erred on the phone, the pharmacist should have been knowledgeable enough to question the overdose.” To help patients detect medication mistakes, we offer a free Drug Safety Questionnaire and Medical History form.