Pharmacist Foul-ups
by Houston Family Magazine
Ask Amy — October 2010
How often do you check the pills you pick up from the pharmacy to make sure what’s inside the bottle matches what the doctor prescribed for you or your child? Even if you did check, how would you even know what the numbers or letters on the pills mean?
Kimberly Roberts has made it her mission to find out. She checks and double checks every order and refill she gets from her pharmacist. She wasn’t always so attentive. In 2007 Roberts came down with flu-like symptoms. The busy mother of 3 headed straight to the doctor, determined not to let the crud slow her down.
“I was like ‘Give me some medication,’” Roberts said she told her doctor. “‘Help me out. Give me anything.’”
Her doctor prescribed antibiotics; but the medicine dispensed by a Walgreen’s pharmacist was actually thyroid medication. The prescription bottle had Robert’s name, address and correct prescription neatly printed on the outside. Fortunately, the pharmacist realized her mistake and called Roberts at home the following morning after she had taken just one dose of the wrong drug.
“Pharmacists are human,” said Gay Dodson, the Executive Director of the Texas State Board of Pharmacy. “They are going to make mistakes.”
Unfortunately sometimes those small mistakes can have catastrophic consequences.
I looked through state records for examples in Harris County. – One Eckerd’s pharmacist gave a patient thyroid medication when he needed drugs for depression, causing the patient to have a stroke. – Another pharmacist who works at an Humble Walgreen’s gave a 10 year-old boy the wrong medication, requiring the child to be hospitalized in a psychiatric unit for 9 days. – At a different Walgreen’s, another pharmacist gave a patient instructions to take a powerful cancer-fighting drug daily. The directions were supposed to read “twice weekly.” The patient overdosed and died.
All of the pharmacists are still practicing in the Houston-area.
“I frankly can’t remember a pharmacist that has had a license revoked for a dispensing error,” said Dodson.
Instead, the State Board has opted to reprimand or fine pharmacists. In some cases, the Board will require more training or suspend the pharmacist.
In all, I discovered just 25 pharmacists out of some 3600 in Harris County who were disciplined for dispensing errors in the last 5 years. In most cases, the Board would never have known about the dispensing errors if the patient hadn’t called to make a complaint. Pharmacists are not required to report errors they make, unless they result in a civil lawsuit.
You can report any errors made by your pharmacist to the Texas State Board of Pharmacy. All complaints must be received in writing. You can download a form online at www.tsbp.state.tx.us or you can call 1-800-821-3205 (option 5) to have a form mailed to you.
While reporting an error after it’s made is important, as parents and consumers, we should be proactive. Dodson says the best way to catch a pharmacist’s error before you take the wrong medication is to always ask for a consultation with the pharmacist (not the pharmacist’s assistant or technician) when you pick up your order. Talking to your pharmacist about why you are taking the drugs may help them catch a mistake before you walk out of the store with bad medicine.
One last check for good measure: When you get home, you can call the National Poison Control Hotline at 1-800-222-1222. By reading the code on the pill to the operator over the phone, they can tell you exactly what drug you’re holding. It should always match the label printed on the bottle.
