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Protecting Yourself from Life-Threatening Pharmacist Errors

Worst Pills, Best Pills Newsletter article April, 2020

A disturbing exposé published in The New York Times on Jan. 31, 2020, entitled “How Chaos at Chain Pharmacies Is Putting Patients at Risk,” highlighted how overworked pharmacists at major national pharmacy chains — such as CVS, Rite Aid and Walgreens — have endangered patients by making potentially fatal errors when filling and dispensing prescriptions.[1]

In one example cited by the Times, a 17-year-old patient developed a pounding headache, nausea and dizziness after taking what she...

A disturbing exposé published in The New York Times on Jan. 31, 2020, entitled “How Chaos at Chain Pharmacies Is Putting Patients at Risk,” highlighted how overworked pharmacists at major national pharmacy chains — such as CVS, Rite Aid and Walgreens — have endangered patients by making potentially fatal errors when filling and dispensing prescriptions.[1]

In one example cited by the Times, a 17-year-old patient developed a pounding headache, nausea and dizziness after taking what she thought were her prescription asthma pills. The patient fortunately realized that her CVS pharmacy had erroneously given her a blood-pressure-lowering medication that had been prescribed to another patient.

In another even more terrifying example, the Times described the case of an 85-year-old woman in Florida to whom the powerful chemotherapy drug methotrexate (TREXALL) had been dispensed by a Publix pharmacy instead of the antidepressant that had been prescribed by her doctor. About two weeks later, the woman died in the hospital from “organ failure.” Notably, methotrexate toxicity can cause several life-threatening adverse effects including kidney failure, liver damage and bone marrow failure.

Citing numerous complaints by pharmacists who work for major pharmacy chains, the Times detailed chaotic work environments that make such medication errors inevitable. Pharmacies are understaffed, with on-duty pharmacists struggling to fill prescriptions, administer vaccinations, answer the telephones, counsel patients and call doctors and insurance companies. At the same time, pharmacists must “[race] to meet corporate performance metrics that they characterized as unreasonable and unsafe in an industry squeezed to do more with less.”

An accompanying article published by the Times on Jan. 31 offered the following valuable tips for how patients can protect themselves from pharmacist medication errors:[2]

  • Check to make sure the patient’s name, address, and birth date and the drug name and dosage on both the printout stapled to the prescription bag and on the bottle or box inside the bag are correct and match exactly.
  • When refilling a medication, check to see if the color, shape and size of the pills are the same as your last prescription. If they are different, check with the pharmacist to confirm that the prescription has been filled correctly.
  • Many pharmacies will include a description of the pills on the prescription label affixed to the bottle. If the description on the label does not match the appearance of the pills inside the bottle, talk to the pharmacist. There also are several websites that describe the appearance of prescription pills.
  • Alert the pharmacy immediately if any mistake is detected.

By being vigilant each time a prescription is dispensed, patients can minimize the risk of serious harm from pharmacist medication errors.





References

[1] Gabler E. How chaos at chain pharmacies is putting patients at risk. The New York Times. January 31, 2020. https://www.nytimes.com/2020/01/31/health/pharmacists-medication-errors.html. Accessed February 6, 2020.

[2] Gabler E. Pharmacists make mistakes. You can protect yourself. January 31, 2020. https://www.nytimes.com/2020/01/31/health/pharmacists-medication-mistakes.html. Accessed February 6, 2020.