Pharmacy Dispensing Errors: Not What the Doctor Ordered

Have you noticed the number of pharmacies opening in your area?  As the Baby-Boom Generation continues to age, there is a marked increase in the number of prescriptions being filled each day.  And the number will continue to increase, with no end in sight.  Retail pharmacy is big business.

It is not unheard of for a busy retail pharmacy to fill more than 1,000 prescriptions each day, with the pharmacist working a 12-hour shift.  Mistakes are inevitable.  A one percent margin of error in a pharmacy filling 1,000 prescriptions each day equates to ten people walking out of the pharmacy each day with a wrong prescription.  One study found that, of 9394 prescriptions handled by a pharmacy over a 12-day period, 141 prescriptions (a 1.5 percent error rate) had potentially serious errors.  The rate of all errors, including less serious errors in filling prescriptions, was more than 12 percent.   See BG Guernsey, et al., Pharmacists’ dispensing accuracy in a high-volume outpatient pharmacy service:  focus on risk management, Drug Intelligence & Critical Pharmacy, Vol. 17, No. 10 at 742-46 (1983 Harvey Whitney Books Company).

Your neighborhood pharmacists are probably competent and trustworthy people, but their jobs are not easy.  They have to supervise technicians, counsel customers, service the drive-through window, deal with insurance companies, decipher doctors’ handwriting, take telephone calls and faxes from patients, doctors and other pharmacies, all while filling a large volume of prescriptions in a busy environment.  Mistakes happen, and when they do, it often leads to someone not getting medicine they critically need, or someone ingesting a medication that does them harm.

Always verify the medications you receive from the pharmacy.  Ask questions.  Do your pills look different than usual?  Is there writing, numbers or markings on the pills, and if so are the markings the same as usual?  If something does not look right, call the pharmacy or your doctor, or better yet, go back to the doctor or pharmacy to review your medicine.  Take your prescriptions to your doctor and have your physician confirm that you are taking the correct medicine.

If you discover that you have ingested the wrong medicine, or if you do not feel well after taking a newly-filled or refilled prescription, get medical attention at once and check things out.  It may be that the medicine you are taking is not what the doctor ordered.


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