Prescription mistakes are rampant and under-reported

Experts: State data doesn't tell full story

PALM BEACH COUNTY, Fla. - Every day, pharmacists count, pour and hand patients their medication.  Medication that isn't always right.

"In this field,  you can't make mistakes," said Helena Castilla, of Lake Worth.

Nearly two years ago, Helena learned they do.

"It was a normal day, we picked up the prescription and came home," she said.

Her ten-year-old son, Nicholas, had been taking Intuniv, a popular medication for Attention Deficit Disorder and was about to swallow a new dose.

"What was it about that moment?" asked Contact 5 Investigator, Katie LaGrone.

"The shape was the same but the color was different.  I looked at the pill and just had a weird feeling," she said.

A call to her local pharmacy confirmed the  suspicion.

"She looked it up and said, 'yea, that's Invega.   What's Invega?' "

Instead of the medication to treat his ADHD, Helena says the pharmacist mistakenly prescribed Nicholas a drug for adults, suffering with schizophrenia. 

"I was like are 'you kidding me?'  She was very forthright in telling me had your son taken it, the next morning he would have been dead, and I lost it,"  Helena describes, shaking her head. 

"The stresses put on these people is, um, amazing," said Dr. Carsten Evans, a former pharmacist turned professor at Nova Southeastern University.  Dr. Evans says pharmacy mistakes are, surprisingly, common.

"You're saying pharmacy errors happen a lot more often than what we ever hear about and what's ever reported?" asked the Contact 5 Investigators.

"Yes," said Dr. Evans.

Dr. Evans now heads up one of two remediation programs nationwide.  NSU's program is, specifically, designed to help error-making pharmacists discover how they made their errors and why.

"If you listen to the people who make medication errors, you'll see that it always comes back to stress. I was filling to many prescriptions, I was this, I was that," he explains.

But state data, obtained by the Contact 5 investigators, shows since 2007 just over 130 of Florida's nearly forty thousand licensed pharmacists have been disciplined for medication errors.  Common mistakes include  giving patients the wrong dosage and/or the wrong drug.

"If you're asking have only 130  pharmacists in the state of Florida made errors in the last 5 years, the answer is no," said Dr. Evans

Florida, like most states, does not require pharmacies to report mistakes.

"Unless there's a death, it stops there. So you're not going to find that error," explained Evans.

Experts call it the under-reported problem in a billion dollar industry, often criticized for putting company quotas over patient safety.

Michael Cohen is Executive Director for the Institute for Safe Medication Practices.  The organization is the only, federally recognized, non-profit dedicated entirely to preventing medication errors.  It's also is one of just a few groups nationwide that gives pharmacy workers a safe outlet to self-report errors. 

The Contact 5 Investigators asked Cohen if company quotas, which put pressure on pharmacists to fill a certain amount of prescriptions in a certain time frame, really exists.

"Yea, they absolutely do. But they [pharmacies] won't publicly say they have quotas," he said.  "We don't have a real good handle on how many errors happens around the country and where they happen," he explains.

Contact 5 Investigators asked him if he thought states should make it a requirement for pharmacies to report errors.

Cohen responded,  "I think really what we need to do is look more at reporting these nationally and fixing the problem.  There needs to be that safety oversight to make sure people are doing what they're supposed to do and to make sure procedures are in place."

So families like the Castillas don't fall victim to another wrong dose.

"Don't trust what they're giving you without you knowing what it is," said Helena.

"When my mom told me it could have killed me, we were all just like, uh--oh my God," exclaimed Nicholas.

The Contact 5 Investigators received the following statement from the National Association of Chain Drug Stores:

Patient safety is a pharmacy's top priority.  Recognizing that human error is a possibility in any profession, pharmacies constantly pursue opportunities to improve safety.  One example is updating and enhancing quality assurance and training programs for pharmacy personnel.  Another example is using workflow and technology innovations to help reduce the chances of human error.  Scanning technology is used in some instances to verify that the medication that has been prescribed matches the medication actually being dispensed.  Also, the use of electronic prescribing is on the rise.  E-prescribing can reduce the risk of errors from prescribers' handwriting and from incorrectly entering prescription information.   

Pharmacies consider even one prescription error to be one too many.  The pharmacy community advocated for legislation that fosters quality assurance programs and patient safety organizations for all healthcare

providers, including pharmacies.  These entities encourage the voluntary reporting of medical and prescription errors in a non-punitive forum, with a focus on strategies and education to prevent errors.  This approach, common among healthcare professions, emphasizes correcting and preventing errors, rather than counting them. 

Expert advice on how to make sure you don't swallow the wrong prescription medication:

- Check to make the medication you were prescribed matches the label on your medication bottle

- Check the patient name on your prescription bottle.  One of the most common errors is patients getting another patient's medication.

- Get to know your pharmacist.  Make sure he/she knows who you are and what your condition is.

- Talk to your pharmacist about your prescription and what you should know about the medication.

To learn more about pharmacy mistakes or how industry workers can report errors:

http://www.ismp.org

Consumers can report pharmacy/pharmacists errors by visiting the FL Dept. of Health

http://doh.state.fl.us/mqa/enforcement/enforce_home.html

Database of pharmacists that have had action taken against them from the Florida Department of Health since 2007. (bitly link: http://scr.bi/Jx0q9s)

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