When things go wrong at the pharmacy


By guest blogger Michael Cohen:

What should you do if you or a loved one discovers that your pharmacy made a mistake when filling your prescription? The chance of something going wrong—anything from a typing mistake to dispensing the wrong drug or dose—is about 1.7% overall according to an Auburn University observational study of 50 pharmacies nationally. Fortunately, of 4,481 prescriptions they looked at, only five were potentially harmful (about 0.1%). Still, any mistake, even if it’s just your name being misspelled, should be reported because it might not be a simple typing mistake. A misspelled name could mean you have someone else’s prescription medication.

If there’s a mistake, many pharmacies have adopted a policy of asking the customer to return the erroneous drug to the pharmacy. They’ll often tell you they’re sorry for the mistake and offer a discount coupon or refund. It’s up to you whether you’re satisfied with this, but most people we hear from are also interested in assuring that the causes of the error are identified and acted upon to avoid similar mistakes that might affect themselves or others in the future. Just providing a discount coupon and/or refunding the cost of the prescription may feel like a quick payoff to make the problem go away. But pharmacy policies that address legal considerations often prevent pharmacy staff from offering an explanation of how the error happened and steps that will be taken in the future to avoid similar events, even though you think they certainly should.

So here’s an option. Ask the pharmacist to confidentially report details of the situation to our nonprofit agency, the Institute for Safe Medication Practices (ISMP). Our organization is federally certified as a Patient Safety Organization (PSO) by the US Department of Human Services, Agency for Healthcare Research and Quality. As such, we are able to guide the pharmacy’s analysis of the event in strict confidence. Such reports cannot be subpoenaed or used against any pharmacy or any other healthcare provider who reports safety issues to our organization, whether it’s a pharmacist, technician, physician, nurse, or other healthcare practitioner. We can also modify the details of reported medication errors so that neither the involved pharmacies nor the patients involved in the errors can be identified. In this way, we can offer expert assistance to these pharmacies regarding medication error prevention while also using the medication error story to educate staff in other pharmacies about the specific type of errors that are happening in pharmacies and how to prevent them. We can also provide recommendations for error prevention to the public, regulatory agencies such as the Food and Drug Administration (FDA), and drug manufacturers.

You, the consumer, can also report medication errors to our organization, and we have made it easy for you to do so by clicking here. We encourage consumer reports of medication errors, but consumers may not know the underlying cause of a mistake. Only the pharmacy where the error happened can tell us how and why the error happened. Errors are often caused by conditions that lie outside the control of the pharmacist. For example, a barely legible prescription from a physician and medications with look-alike names can lead to an error. How the information about a drug is presented on the product label can also cause an error, particularly if the label looks remarkably similar to the labels on other medications, or the information on the label is confusing. Thus, we can learn more about the causes of errors if those who are directly involved in making them report the event to us. However, we also need to hear about the error from the patient’s perspective, so please do let us know if you become the victim of a medication error. 

Whether it’s a problem with the medication label or package, or a problem with the processes used to fill the prescription, our job is not only to educate others about error prevention but to also advocate for healthcare industry changes that make medication errors less likely. All of these core ISMP activities are carried out for the public good without compensation. Funding is provided through grants and donations to ISMP, as well as payments received for certain business activities such as educational programs and consultations. You can see some of our work on our Web sites at http://www.ismp.org and http://www.consumermedsafety.org.
Please note: ISMP has no ties to the government or boards that license pharmacists and pharmacies. Thus, we have no authority to enforce regulations or ensure compliance with recommendations we make to prevent errors. Such an arrangement is required in order for us to carry out our work and serve as a Patient Safety Organization. If you have been involved in a very serious error and you a looking for regulatory follow-up, you can report the event to your state’s pharmacy licensing boards or, for hospital errors, your state’s department of health. But, please also report the event to ISMP so we can allow other pharmacies to learn from the mistake and take preventative measures to avoid the same type error.

For information on the Institute for Safe Medication Practices' consumer website go www.consumermedsafety.org
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