When Norma Segui gave daughter Kimberleigh her usual medication from the CVS Hope Mills, NC Pharmacy, Kimberleigh said her stomach felt funny. Because the pill looked different from the usual medication—this pill was pink and marked with an X, instead of the usual yellow pill with a number on it—Ms. Segui immediately called CVS. She was advised to return the medication, so the error could be fixed. Instead of the 5 milligram medication prescribed by the doctor, the pharmacy had dispensed 10 milligram pills, which contained twice the recommended dosage and had included two extra pills. The pharmacist commented that Kimberleigh might experience sleepiness and an upset stomach.
The pharmacist corrected the prescription and told Ms. Segui that the pharmacy was short staffed, which was an explanation but not an acceptable excuse. The same pharmacy was issued a written warning for a 2013 error when it gave a patient Topiramate, a seizure medication, instead of Tramadol, a general pain reliever. In these cases, the patients did not suffer serious harm.
Why Do Pharmacists Make Mistakes?
Some believe performance metrics imposed by corporate pharmacies are at the root of many pharmacy mistakes. Performance metrics is a system that measures how many prescriptions are filled by the pharmacist and how fast he performs this task. It also includes the number of flu shots given and phone calls made to urge patients to get their prescriptions filled. Other factors which increase the chance of pharmacist error include:
- Interruptions. Concentration is required to correctly fill prescriptions. However, the multi-tasking necessary to work in a pharmacy creates distractions as often as every two minutes according to a study published by the Institute for Safe Medication Practices (ISMP).
- Understaffing. In addition to completing their own work, the supervising pharmacists are responsible for verifying the work of low-wage and high turnover technicians. Under constant time pressure, the verification step is where many errors occur.
- Fatigue. Many pharmacists work long shifts—up to 14 hours a day. Their work requires standing for most of the work day and eating while standing over their computers.
- Unreasonable Time Demands. While observing a 15 minute wait time, the pharmacist must also take phone calls, counsel patients, administer immunizations, transfer prescriptions to other pharmacies, and transcribe new prescription orders called in by physicians.
- Drive-through windows. Accuracy is more important than speed in correctly filling prescriptions, but customers expect quick service when using a drive-through. This can increase the likelihood of errors.
Common Pharmacy Mistakes
Not everyone spots a medication mistake, but the result of an error can cause overdose, toxicity, poisoning, or death. According to statistics by the Food and Drug Administration (FDA), pharmacy errors cause one death a day and harm at least 1.3 million people yearly in the U.S. Common mistakes include:
- The right drug is dispensed in the wrong strength. Kimberleigh received the right drug but at twice the dosage written by the doctor. The harm caused in this situation may not be evident immediately and only discovered over time.
- The wrong drug is dispensed. A distracted pharmacist or technician may mistake similar sounding drugs for each other or choose the wrong drug altogether.
- The wrong number of pills are dispensed. Taking more or less of a prescribed medication will negatively affect treatment.
- The wrong person receives the drug. Mistakes can occur when a prescription is directed to another person in the same family or to a customer with a similar name.
- Label mistakes. Wrong dosing instructions can be written on the label. A drug which is meant to be taken once a day can cause harm if mislabeled to be taken 3 times a day.
- Dangerous drug interactions. Patients who see more than one doctor may receive multiple medications, which may cause a pharmacist to overlook dangerous drug interactions or contraindications.
We Can Help
A patient should not have to pay for the injuries caused by pharmacy errors. If you or someone you love suffered injuries due to a prescription error, you need information that can help. Contact the pharmacy error lawyers of Kennedy Hodges at 888.526.7616 for a free consultation, or fill out our confidential online form.
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