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Right
Drug, Wrong Patient
by Andrea Rock
As
a rule, the pharmacy's
proficiency and authority is little doubted. But the rate
of pharmacy errors is much higher than people think. Imagine
what would happen if the drug dispensed to you were not the
proper one. The following article tells us more about pharmacy
errors.
At
breakfast, seven-year-old Gabrielle Hundley took the first
of two pills that would change her life. The
new prescription that her mother, Peggie, had gotten filled
at the Rite Aid in Rock Hill, S.C., was for Ritalin, a drug
used to treat attention deficit-hyperactivity disorder.
In an emergency room later that day, February
21, 1995, doctors discovered that the little girl hadn't taken
Ritalin at all, but a high dose of Glynase, a diabetes medication.
In court the next year, the Hundleys' attorney argued that
the pills were incorrectly dispensed, and contained 16 times
the normal starting dose for adult diabetics, causing Gabrielle's
blood-sugar level to plummet so severely that she suffered
permanent brain damage. The jury awarded the Hundley family
$16 million. Rite Aid is .
Pharmacy transactions seem so straightforward.
How often could they go awry?
While there are no definitive national statistics,
there is evidence suggesting that drug-dispensing mistakes
are more common than you think. In a 1997 nationwide survey
conducted by the trade publication Drug Topics, 53
percent of pharmacists admitted having made errors in the
preceding two months. A June 1996 survey of 3361 pharmacists
in California and Oregon revealed that errors occurred at
an annual rate of 324 per pharmacy—nearly one a day.
"Ten years ago, an acceptable error rate was
considered one per year per pharmacy," says Ralph Vogel, president
of the Guild For Professional Pharmacists, a union representing
2000 pharmacists. "What we're seeing today is the chaos that
comes from
and other new stresses in the pharmacy. "
The
pharmacy industry insists that worries over error rates are
overblown. Nevertheless, many state regulators,
consumer advocates and pharmacists contend that a revolution
in the retail drug business is causing problems by increasing
workloads.
They point to two factors: First, overall
prescription volume keeps rising─up 30 percent between 1992
and 1997, according to IMS Health, a health care information
company. Second, the percentage of prescriptions paid for
by insurance or
has risen from 28 percent in 1991 to 60 percent in 1997. These
third-party payers are imposing ever-lower
rates on pharmacies, which must churn out a high volume of
prescriptions to keep profit margins up. Even the
Big Four chains—Rite Aid, CVS, Eckerd and Walgreens─are
affected.
Against
this backdrop, too many people are taking the prescription
transaction for granted. Indeed, for the past nine
years, Americans responding to Gallup Polls have ranked pharmacists
as the country's most honest and ethical professionals ahead
of clergy members. No wonder so many people assume nothing
can go wrong. "I had blind faith," says Peggie Hundley.
Here's what you need to know to protect your
family:
You can't rely solely on your doctor.
Most physicians get only one year of formal training in medical
school on the use of prescription drugs. And, generally, continuing
education on medications is not required.
In contrast, many states require pharmacists
to complete an average 15 hours of continuing education each
year. And
there's no dearth of homework: new drugs are pouring into
the market, stimulated by a 1992 program shortening the
's
drug-approval times. In the past two years, 92
new drugs hit the market—compared with 125 approved for
the previous five years.
So don't assume you would never leave your
doctor's office with a problem prescription. Ruth Paxton,
44, of Dayton, Nev., trusted her doctor implicitly when she
sought treatment for a sinus infection in July 1992.
Years earlier, Paxton had experienced severe
allergic reactions to the antibiotics penicillin and Keflex.
Unaware of the severity of her past reactions, her doctor
prescribed the antibiotic Ceftin, which can cause life-threatening
allergic responses in people with extreme sensitivities to
either of the other two drugs.
Within 20 minutes of taking Ceftin, Paxton's
throat began to swell, making it difficult to breathe. Swift
self-treatment with an anti-histamine stopped the reaction.
Nevada's
board of pharmacy reprimanded Paxton's pharmacist, saying
he should have warned her of the potential for allergic reaction.
A white coat does not a pharmacist make.
The burden of knowing about potentially dangerous drug reactions
is one reason pharmacists must complete five or six years
of academic training. Yet increasingly, the white-coated person
who dispenses medicine isn't a pharmacist at all but a pharmacy
technician. Depending on the state, such techs may have nothing
more than a high school degree and on-the-job training.
As pharmacy chains face squeezes on profit
margins, the use of techs is growing. Why? Techs typically
earn $5 to $12 an hour─compared with the average of $30
to $39 an hour for registered pharmacists.
Of course, pharmacists are supposed to check
technicians' work. Failure to do so was cited as a major cause
of dispensing errors by nearly a third of pharmacists in the
Drug Topics survey.
You could get the right drug, but the wrong
dose. Hazel Van Hattem of Crete, Ill., says there were
two pharmacists and three technicians on duty on May 30,1995,
when she picked up a refill of Coumadin, a powerful blood-thinning
medication, for her husband, Ernest. "At the trial, they said
they couldn't be sure who filled the prescription," says Hazel,
referring to her lawsuit against Kmart. Her attorney argued
that whoever filled the prescription did so with pills containing
5 mg. of Counmadin rather than Ernest's usual 2 mg.—an overdose
that caused massive bleeding and led to his death. A
jury levied an $810 000 judgment against the pharmacy.
A Kmart spokesperson says the company is appealing.
Some dispensing errors can be attributed to
unreasonable workloads. Three medical studies conducted over
an 11-year period found a correlation between pharmacists'
workloads and error rates :"There does appear to be a greater
risk of errors when a pharmacist is expected to fill more
than 24 prescriptions per hour," says Elizabeth Allan Flynn
of Auburn University's School of Pharmacy. Increasingly, pharmacists
say, pushing beyond that rate is not unusual.
The safety net has holes. Most pharmacies
rely on computer setups that are supposed to be updated regularly
with information about new drugs or new risks for existing drugs.
But these systems don't always work.
In a study reported in the Journal of
the American Medical Association in 1996, Raymond Woosley,
chairman of the department of pharmacology at Georgetown University
Medical Center, and his colleagues presented two prescriptions
for the same patient to 50 pharmacists in the Washington,
D.C., area. One was for the antihistamine Seldane; the other
was for the antibiotic erythromycin.
Since 1992 the FDA and the drug manufacturers
have issued warnings that mixing the two drugs could be fatal.
Still, 32 percent of the pharmacies filled the prescriptions.
Of
the 48 pharmacies using computers to flag adverse interactions,
29 percent had programs that failed to issue an alert.
In some cases, Woosley says, pharmacists had shut down the
systems or overridden them.
And what about the patient information leaflets
stapled to prescription bags at most pharmacies? These are
also designed to give added protection against drug interactions
or side effects. They usually aren't prepared by pharmacists
or physicians—but by commercial vendors. And they're often
vague or out-of-date.
Little watchdog oversight exists. Most
state boards don't require pharmacies to report dispensing
errors. And national error-reporting programs such as one
run by U.S. Pharmacopeia (a nonprofit group that sets drug-manufacturing
quality standards) are voluntary.
Drug chains, however, usually require pharmacists
to submit error reports to management. But even those internal
reports don't always prevent future errors.
Malvina Holloway, 59, of Mobile, Ala., received
a bottle filled with Tambocor, a dangerous heart-rhythm-altering
medication, rather than the breast-cancer drug Tamoxifen that
her oncologist had prescribed. Holloway didn't discover the
mistake until five months and two refills later.
Luckily, she did not experience any adverse
reactions to the heart drug, but Holloway was distressed that
her cancer treatment was delayed. She
Harco Drugs, Inc., the regional chain where the mistake was
made. Her attorney presented 233 incident reports that had
been submitted to Harco management, the majority involving
dispensing errors at their stores over the preceding three
years. Holloway won a $255 000 jury award.
Such awards have motivated chains to improve
internal procedures on error reports. But Carmen Catizone,
executive director of the National Association of Boards of
Pharmacy, which represents state licensing boards across the
country, argues for greater oversight: "We are proposing
that each individual pharmacy be required to report serious
dispensing errors to the state board."
The ultimate responsibility of protecting
himself, though, rests with the consumer. In most states,
pharmacists are required by law to counsel customers about
new prescriptions. Nevertheless, most customers turn down
offers for a "show and tell."
Says Stephen Giroux, a pharmacist in Middleport,
N.Y. "If people understood the harm that could be done to
them by a dispensing error, they wouldn't treat going to a
pharmacy like going to a fast-food store."
How to Protect Yourself
* Take Notes: At your doctor's office,
write down the generic and brand names of your prescribed
medicine, along with its purpose and the dosage. That way
you can double-check the medication the pharmacist hands you.
* Inform Everyone: Remind both your
doctor and your pharmacist of any drug allergies you have,
as well as any other medications you're taking.Include
over-the-counter pain or cold remedies, vitamins and herbal
supplements.
* Check Refills: Make sure the pills
are the same color and size you usually get. If they're different,
assume they're wrong until a pharmacist examines them.
* Shop Off-Peak: Avoid getting prescriptions
filled on a Monday, traditionally a pharmacy's busiest day.
Call in refills a day or two ahead to lessen chances that
your prescription will be filled during busy hours. If you
get your prescriptions by mail, order them at least two weeks
before you need a refill. Most importantly, if you feel sick
after taking a newly prescribed drug, call your physician
immediately.
—A.R.
(1 645 words)
(From Reader's Digest,Sept., 1999 )
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