Wednesday, February 9, 2011

It's An Error

There's another prescription error in the news -- in Colorado, a woman was given someone else's prescription (the person had a "similar sounding" name) and she took it home and took a dose. She realized soon after that a different name was on the bottle. Unfortunately the drug was methotrexate and the woman is in her first trimester of pregnancy, so now she must await the possibility of miscarriage or birth defects.

This is awful of course, and according to one news report, the woman said the pharmacist (and we'll assume it actually was the pharmacist and not other support staff) knew that the drug was methotrexate and even helped her pick out some prenatal vitamins.

Obviously there was a breakdown here --- the pharmacy says their policy is to double-check the name and address when handing out a prescription. In addition, the offer of counseling or at least the quick 'show and tell' wasn't done. I'm sure the pharmacist couldn't feel worse. Reading about this kind of thing is a good wake-up call for all of us not to let ourselves slide into any shortcuts because of the pressure of doing things 'fast.' (Yeah, I know.... all the forces are still against us on that...... See: every pharmacist's chief complaint..)

Believe me I'm not blaming the patient for any of this, but it's also a good reminder to folks who are picking up prescriptions--
1. Please don't get visibly irritated when we ask (again!) to verify your name, date of birth or address.
2. Look carefully at your medication bottle and receipt before you take any of it.
3. Look at the patient information leaflet that is provided with your prescription. If this patient had done so, she would have immediately realized this medication was NOT for her.

Another reminder of the human factor today. For all the venting we do on our pharmacy blogs, none of us wants to see this happen.


Grumpy, M.D. said...

In case you missed it, the FDA recently issued a warning that Qualitest, Inc. had erroneously labeled stock bottles of Vicodin as Phenobarb.

The Redheaded Pharmacist said...

This is a scary situation for that patient. I hope things turn out well for her. And yes Dr. Grumpy, we received the recall notice today at work. It really scares you to think that a company could completely mix up two medications like that.

Anonymous said...

Recently we received recall notice at the manufacturing level for the company that producing nebulization plasti-amps that they screwed up and put wrong (liquid) drug in the dosage form delivery devices. THAT is really scary. It was an accident waiting to happen, because anyone looking at the embossed drug name on the container realizes that it's nearly impossible to read. This is 'clearly' an FDA-mandate issue.

bcmigal said...

This is. of course, the pharmacist's worst nightmare. Even the best of us go home at night and say a prayer that we observed the 5 "rights" of patient care. But you are correct when you say that pts answer "yes" to questions without really listening and often refuse counseling because "I've taken this drug before." I tell patients that we are alway grateful when they call with questions about their prescriptions. We would rather have 100 inquiries than one injury due to med error.

pscearce said...

As a doctor it also bothers me that people think there will NEVER be a mistake made anywhere. It has become accepted that because mistakes are 'never events' any mistake must mean you are undeserving of the letters after your name. Humans are working here. Humans make mistakes.