Avoiding Pharmacy Errors

When pharmacists are asked to work long hours under grueling pressure, mistakes happen. And although many errors are minor, some of them can be extremely grave.

It was Monday, one of the busiest days of the week, and the pharmacy in South Carolina was understaffed. A pharmacist handed a mother a bottle of pills that was supposed to contain Ritalin, a medication to control her 8-year-old daughter's hyperactivity. In fact, the pills inside were a diabetes drug, at 16 times the adult dosage. After taking the medication, the little girl sank into a coma and suffered permanent brain damage. The pharmacist who made the mistake, investigators discovered, was at the end of a 12-hour shift -- and a 60-hour work week.

Statistics suggest that he's not alone. Pharmacists exhausted by the demands of a burgeoning health-care industry are making errors while filling prescriptions for customers, according to recent government reports.

More than 100,000 Americans die each year of adverse drug reactions, according to a landmark report in the Journal of the American Medical Association -- making such reactions one of the six leading causes of death in the U.S. No one knows how many of those deaths are the result of errors in dispensing drugs, but observers say pharmacy mistakes may play a role. When researchers analyzed 9,846 prescriptions filled at a large hospital's outpatient pharmacy in Springfield, New Jersey, for example, they found 1,371 mistakes, ranging from bottles containing the wrong pills or the wrong dosage to labeling errors. In other words, mistakes were made in roughly one in eight of the prescriptions.

And some of these errors can be deadly. Wrongful death suits involving prescription errors have been filed in Oklahoma, Connecticut, and Texas, and cases involving serious injuries have cropped up in many other states.

"There's a real crisis in pharmacies," says Fred Mayer, president of Pharmacists Planning Service, Inc., a lobbying organization in northern California. "And at the heart of it is overworked pharmacists. The system we have has pushed them beyond the breaking point."

Long Hours, Grueling Pressure

If the white-coated pharmacist who fills your prescription looks harried, it's no wonder. The conditions at many pharmacies are akin to sweat shops, analysts say. "In some retail locations, pharmacists are being asked to work 12-hour shifts, sometimes back to back," says Phillip Grauss, a senior pharmacist at Kaiser Permanente in Petaluma, California. "Pharmacists are being asked to handle 30 prescriptions an hour. That's two minutes to fill a prescription, counsel the patient, and check for potential drug interactions. Pharmacists are under incredible pressure to crank out prescriptions. It's no wonder mistakes are being made."

Part of the burden comes from soaring demand for prescription drugs. In 1994, Americans bought more than 2 billion prescriptions. Today that number has grown to over 3 billion, according to the National Association of Chain Drug Stores (NACDS).

Meanwhile, the paperwork involved in filling each prescription has become more complicated. Under managed care, for example, each insurer has its own formulary -- the list of drugs it offers under its plan. "Your doctor may write a prescription for drug A. But when we punch it up on the computer we may find that your insurance plan doesn't cover drug A but does cover drug B," explains Bill Kean, a pharmacist in northern California. Before a pharmacist can substitute one drug for another, he must check back with the doctor and the patient for approval -- adding to the time pressure as other prescription orders pile up.

Pharmacists are also required by federal law to counsel customers about prescription drugs. Many, however, just don't have the time to spare. When the state pharmacy board in Massachusetts sent undercover agents to various pharmacies, they found that 64 percent failed to offer or give adequate counseling.

The obvious solution is to add more pharmacists and relieve a little of the pressure on them by giving them adequate breaks, say pharmacy groups. But as the number of prescriptions being written has soared, the number of pharmacists to fill them hasn't kept pace. NACDS estimates that between 2004 and 2010 the number of pharmacists will increase by almost 8 percent however, prescription volume is expected to increase an estimated 27 percent.

Is There a Pharmacist in the House?

To cut costs and meet the increasing demand for prescription drugs, pharmacies are turning some duties over to pharmacy technicians or clerks, who often have little training and are paid only $6 to $12 an hour. In some states technicians -- who must always work under a pharmacist's direction -- are allowed to pull drugs off stock shelves and even fill prescription bottles. They also enter prescriptions into the computer and call doctors to authorize prescription refills.

"When you go in to get a prescription filled, in fact, you may never have any contact with the real pharmacist but only a clerk who doesn't understand the drugs being dispensed or possible interactions," warns Mayer. Retail pharmacies used to be required to have one pharmacist for every one pharmacy technician on duty. This is no longer true. In fact, some states allow up to four technicians for every pharmacist on duty.

Pharmacists are legally responsible if a mistake is made, and some have been sued for millions of dollars. But pharmacy technicians have no legal responsibility -- which means they may have less incentive to double check the prescriptions they're handing out, says Grauss. In a 1998 study by the Virginia Board of Pharmacy, pharmacists caught an average of 6.5 technician mistakes a week. But although one study found that errors rose along with the ratio of technicians to pharmacists, others have found that technicians are no more likely to make dispensing errors than pharmacists.

Many pharmacy errors, of course, go undetected. US Pharmacopeia's Medication Errors Reporting Program received 90,000 reports of pharmacy errors in 2003 -- nearly 40 percent of which were attributed to performance deficit. But a 2007 report from researchers at Ohio State University estimated 5.7 errors per 10,000 prescriptions, or 2.2 million dispensing errors a year.

Of course, beyond the time crunch they face, pharmacists have plenty of other challenges. They have to decipher the almost illegible handwriting of many doctors. (In one court case, a doctor's orders were so sloppily written that they couldn't be used as evidence!) They must also keep track of a bewildering number of new drugs with complicated and often similar sounding names -- drugs like Cerebyx, Celexa, and Celebrex, each of which is prescribed to treat very different conditions. One in every four medication errors, studies show, is a name-confusion error.

But job problems other than overwork may also play their part. In some pharmacies, conditions verge on the absurd. In one nationwide grocery store chain that boasts a drug department, if a customer comes up to the prescription counter asking where dog food or canned tomatoes are, pharmacy personnel are required to stop what they're doing and lead the shopper to the right aisle. In another, pharmacy workers have been asked to divide their time between filling prescriptions and scooping ice cream cones. Such distractions are more than a mere annoyance for pharmacy personnel. A 1999 study at Auburn University's Department of Pharmacy Care Systems found that distractions and interruptions can double the number of mistakes made in filling prescriptions.

Ask Your Pharmacist

"The problem of pharmacy errors is only going to get worse as the number of prescriptions being written increases and pharmacists are put under more and more pressure to work as fast as they can," warns pharmacy expert Mayer.

Some states are already moving to try to remedy the problem. In North Carolina, for instance, drugstores are now legally responsible when an overworked pharmacist makes a mistake while filling out more than 150 prescriptions a day.

What can you do to make sure the prescription you pick up contains the right drug at the right dose? Take an active role, says Mayer. If you have questions, ask to speak directly to the pharmacist. "You should always ask, 'What's this for? How do I take it and for how long? Can it interfere with anything else I'm taking? What if I miss a dose?'" Remember, by law pharmacists are required to provide counseling on any and all prescription drugs.

It's equally important for you to give your pharmacist all the information he or she needs. Make sure you understand exactly what you're taking and why, and tell the pharmacist what other drugs or supplements you're taking. "It's up to you to keep track of the drugs you're prescribed," says Mayer.

"I almost hate to tell people to demand to see the pharmacist, because it's only going to add to the pressure they are under," says Mayer. "But when it comes to making sure patients get the right drug in the right dosage, the person you can count on is your pharmacist."

References

Szeinbach,S., et al. Dispensing errors in community pharmacy:perceived influence of sociotechnical factors. International Journal for Quality in Health Care: Volume 19, Number 4: pp. 203-209, June 2007.

Preventing Medication Errors, Institute of Medicine, National Academies Press, 2006.

Flynn EA, et al. Impact of interruptions and distractions on dispensing errors in an ambulatory care pharmacy. Am J Health Syst Pharm 1999 Jul 1;56(13):1319-25.

Lazarou, J, et al. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA 1998;279:1200-1205.

Kistner UA, et al. Accuracy of dispensing in a high-volume, hospital-based outpatient pharmacy. Am J Hosp Pharm 1994 Nov 15;51(22):2793-7.

National Association of Chain Drug Stores. Retail Prescription Drug Market -- Number of Prescriptions. 2004.

National Association of Chain Drug Stores. Community Pharmacy Outlets. 2004. http://www.nacds.org/user-assets/pdfs/facts_resources/2004/Retail_Outlets2004.pdf

National Association of Chain Drug Stores. Industry Facts-at-a-Glance. 2005.

NC Division of Public Health. Dispensing Drugs by Public Health Nurses -- Part I. April 2005.

Virginia Board of Pharmacy. Frequently Asked Questions.

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