I was, as always, in a hurry. I grabbed the small bag, scribbled a check for the pharmacist's assistant, and dashed out. The next morning, I opened the new container. My pills were blue. Huh? I thought the company must have changed the color. But a tiny doubt bothered me. I read the pharmacy prescription label.
Then it hit me. The names were similar, but not the same. I'd almost taken the wrong drug.
The same thing had happened to me a few months earlier with another medication at the same large, well-known pharmacy. At the time, I'd assumed it was the rarest of flukes.
Now, I had questions.
How Often Do Errors Occur?
Experts use words like "common" and "frequent," but statistics vary. Most errors are reported voluntarily by pharmacists or patients. Lisa Stump, MS, RPh, clinical coordinator of drug use policy at Yale-New Haven Hospital, says this is an unreliable way to determine frequency.
But Stump believes we shouldn't be focusing on statistics. "We know medication error is common. Quantifying the incidence will not assist us in making changes we already know need to be made," she says.
Marci Kropff, PharmD Fellow of the Institute for Safe Medication Practices, agrees. "We don't encourage a focus on statistics. The information isn't an accurate representation of the prevalence of errors because there's no way to capture this number."
Are Certain Drugs More Often Dispensed Incorrectly?
Sound-alike or look-alike drug names are known problems. Here are some examples:
Most dispensing errors occur in frequently prescribed drugs. Tony Grasha, PhD, is a University of Cincinnati psychology professor working on a National Association of Chain Drug Stores project to reduce prescription errors. He names the following drugs as being among the top 10% of the most troublesome medications with regard to errors in the last five years:
Premarin (wrong strength)
Lanoxin (wrong strength)
Amoxicillin (wrong strength)
Ortho-Novum (wrong strength)
Prednisone (wrong drug)
Procardia XL (wrong strength)
Synthroid (wrong strength)
Xanax (wrong strength)
Zantac and Tagamet (wrong drug)
Imipramine and Amitriptyline (wrong drug)
Why Do Errors Happen?
There are several factors that contribute to consumers taking the wrong prescription home. Some factors include the following:
Stress and distraction
—everyone, even pharmacists, can be distracted and stressed while on the job.
—a high volume of prescriptions combined with time pressures.
—resulting in fewer pharmacists on duty.
—a scrawled prescription can be misinterpreted.
—stocking drugs by manufacturer places look-alike packages in a row. Alphabetical arrangements put sound-alike products together.
—it's difficult for pharmacists to keep up with the sheer volume of new medications. The number of drugs approved annually has doubled since the 1960s.
—who don't slow down to check prescriptions or ask questions.
What Is Being Done to Improve the Process?
Customers, pharmacists, doctors, and professional organizations are all serious about minimizing errors. Many pharmacists routinely stay after work to recheck prescriptions they filled that day.
Some of the many methods of reducing errors include the following:
Professional standards and training.
Automation and computer cross-checks.
More attention paid to drug naming, to avoid sound-alikes.
Changing packaging so that products don't appear the same.
Computer-generated prescriptions instead of handwritten ones.
Redesign of pharmacy drug storage.
Computerized systems that alert pharmacists to potential errors.
Testing of ways to lower pharmacy stress and distraction.
How You Can Protect Yourself
Here are some tips on how to protect yourself against medication errors:
Open the bag
. Check to be sure that you've been given what you should have. Grasha, in his onsite pharmacy study, watched hundreds of customers.
"Three-quarters immediately open and examine their photos at the film center. Less than one-third of pharmacy customers look inside the bag," he notes.
Don't sign too quickly
. The paper pushed across the counter—the one most of us sign automatically—is an agreement that you've gotten the information you need. Don't sign it without checking first.
Read the label carefully
. Read every word. Check for the name of the drug and the condition it's being prescribed for. If they're not on the label, ask the pharmacist to add them. If the name isn't the name your doctor told you he was prescribing, ask the pharmacist. Never assume you're just being given a generic product.
Look at the drug
. If it's a refill, does it look the same as the previous batch? If not, ask the pharmacist.
Ask for printed information sheets
. And if you're asked by the pharmacist if you need counseling on the medication, say "Yes!"
. Don't be embarrassed to get the information you need. If the question is complicated, ask to speak to the pharmacist.
Never assume anything
. Don't ever take for granted that you have the right medication.
"Two-thirds of errors are caught by customers," Grasha says. "Errors are part of the system and consumers are a very important part of the process."
Buy a book
. A current consumer guidebook to prescription medications, with colored illustrations, should be part of your home library.
Keep a record
. Write down information about each of your prescriptions. Grasha suggests taping one pill on an index card and writing down the name, what the medication is for, the dose, and color/markings. Or put the same information, along with a sample, into a separate envelope for each medication.
. At the doctor's office, write down drug names and what they're for. Compare your notes to your prescription at the pharmacy.
Next time, I'll know to do things differently. As Stump says, "Consumers must make the effort to educate themselves, to partner with their doctors and pharmacists to protect their health. Healthy patients are everyone's goal."
Please be aware that this information is provided to supplement the care
provided by your physician. It is neither intended nor implied to be a
substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER
IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the
advice of your physician or other qualified health provider prior to
starting any new treatment or with any questions you may have regarding a