Errors That Kill

Several years ago, a gentleman was picking up a prescription for his wife, and unbeknownst to him at the time, the medication prescribed by the doctor was not what he took home.

The error started when the doctor’s office phoned in the prescription to the pharmacy. The technician (not the pharmacist) took the order and gave the information to the pharmacist. Still, there was a big problem: she chose the wrong medication.

Notably, most states do not take phone calls for medication orders. But this particular case was in a state (Missouri) that still allowed it. As the pharmacist filled the prescription, alarm bells should have been going off for the amount of medication that was in the note: a lethal dose, to be sure, and this is something that should have caught his eye. He later testified in court that he should have detected the error, but the pharmacy was busy, things were moving quickly, and he didn’t catch it.

The technician did offer counseling upon checkout but the gentleman picking up the prescription declined. Maybe he was also busy, but this was also a tragic mistake as, most likely, a review of the medication at this juncture would have caught the error. Maybe, maybe not.

The husband took the medication home to his wife, who proceeded to take it per the dosing instructions. During the next month, she poisoned herself to the point of death.

Lessons We Can Learn

Lessons we can learn from this situation:

• Pharmacy computer systems should be equipped with controls/flags/warnings when a pharmacist is dispensing a dangerous drug.
• There should, possibly, be a federal law to standardize the processes so that every state has the same ability to catch errors.
• Federal laws should contain requirements on the number of pharmacists required to be on staff – particularly when staffing busier pharmacies.
• A pharmacy technician should NEVER be allowed to take a prescription over the phone. These calls (if permitted at all) should be taken by pharmacists only.
• Pharmacists should review a patient’s medications they are taking against the newly prescribed medication as a control to ensure the appropriateness of the medication and to catch any potential drug interactions.
• Consider allowing ONLY computer-generated prescriptions using software programs written to raise questions and flag dosing that could be in error.

Whatever can be done to set up a pharmacist to succeed SHOULD be done in the patients’ interests. After all, no pharmacist sets out one day to intentionally harm someone.

If you have been a victim of pharmacy malpractice, contact our board-certified attorneys today to start a free case review. You may want to order a FREE copy of our book, “Making Pharmacies Pay for Their Errors,” to learn more about taking action because of a prescription error. Order your free book today by filling out our confidential contact form or by calling 713-425-6445.