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Pharmacy Mix-Up Spotlights Errors

Jan 20, 2005 | Bucks County Courier Times

Christine Miller took one pill and said she soon felt an indescribable sensation she tried to shake off. When she checked the paperwork that accompanied her prescription, it said she had been given the heart medication Digitek and not the antibiotic Zithromax her doctor had prescribed. The prescription she had taken Jan. 14 was for another Miller, a 65-year-old man.

Christine Miller, who is 52 and visually impaired, called a poison control center the same day she took the medicine and read the paperwork. The center told her to go to the emergency room.

After she hung up with the center, an employee from Rite Aid in Bristol called to apologize for the mix-up.

Miller, of Bristol Township, went to Lower Bucks Hospital and got a blood test and checkup; she said she was fine and suffered no adverse effects from the pill. She also returned to Rite Aid and picked up the correct prescription.

The Rite Aid Corp. Tuesday acknowledged the error. The person who handed Miller the prescription Friday was either a pharmacist or an assistant who didn't verify her name and address, a company spokeswoman said. The spokeswoman wouldn't give specifics as to the incident, however.

Rite Aid and many other pharmacies rely on computers, bar-coded labels and automation to help the pharmacist dispense prescriptions accurately. Still, mistakes do happen when humans fail to follow company procedures, corporate spokeswoman Jody Cook said, referring to what happened to Miller.

"An associate was not diligent in checking the name and the address," Cook said, adding that the staff at the Rite Aid on Pond Street in Bristol has been retrained. "We're very happy that no one was hurt."

Cook said the Bristol pharmacy reported what happened to Rite Aid's corporate offices, which is company policy, but the error most likely wouldn't be reported to the state because it doesn't have to be.

Brian McDonald, a spokesman with the Pennsylvania Department of State, which regulates pharmacies, said prescription errors are tracked through voluntary reporting. There's nothing in the law that says prescription errors have to be reported to the state, McDonald said. That's the case in most states, according to industry experts.

According to the Food and Drug Administration, medication errors kill an average of one person daily and injure 1.3 million annually.

That number was based on a study five years ago that sparked improvements and cut down on prescription errors, said Sherrie Borden, a spokeswoman for the U.S. Pharmacopeial Convention Inc. The nonprofit agency sets standards for medications and promotes their safe use. The organization maintains a confidential database of medication errors for hospitals and healthcare professionals.

"Pharmacies are very aware of what they need to do," she said. "They have checks and balances."

She said the key is for consumers to be more knowledgeable about their health.

The two pharmacists who work at the Rite Aid in Bristol have licenses in "good standing" with the Pennsylvania Department of State's Licensing Bureau. No disciplinary actions were found for either pharmacist, the records show.

The Massachusetts Board of Pharmacy recently studied 51 pharmacists who had committed medication errors. The study reported most of the errors were made in dispensing the incorrect drugs or the incorrect strengths (88 percent). Sixty-three percent of errors were committed with new prescriptions. Forty-five percent were committed with prescriptions handwritten by doctors.

"Too many telephone calls" and an "unusually busy day" were the top two distractions cited by the pharmacists in the study, the board said. In 41 percent of the cases, pharmacists said the mistakes occurred because there weren't enough workers to double-check a prescription, the board said.

A study by the University of London's School of Pharmacy showed most prescription mistakes occurred because of "slips in attention."

The Pennsylvania Board of Pharmacy investigated 700 complaints of "improper dispensing" of prescription drugs from 2000 to 2004. The yearly breakdown: 166 complaints in 2000, 126 complaints in 2001, 122 complaints in 2002, 149 complaints in 2003 and 137 complaints in 2004.

From 2000 to 2004, the state Pharmacy Board disciplined 101 pharmacies and pharmacists for "improper dispensing." The yearly breakdowns: 37 in 2000, 19 in 2001, 18 in 2002, 16 in 2003 and 11 in 2004. During that period, 66 pharmacies and pharmacists paid fines to the state. Nine had their licenses suspended. Three licenses were revoked. Two licenses were voluntarily surrendered.

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