A very simple pharmacy error resulted in the death of a boy after he received the wrong medication and experienced severe complications. The child received the same medication to treat his sleeping disorder for a year and a half before taking the medicine with the wrong ingredients and dying in his sleep. A blood screening after his death revealed that not only was the medication prepared wrongly, but the dose of the incorrect medicine was lethal. There was no shadow of a doubt that the pharmacist’s error cost the child his life, begging a discussion over what forms of oversight are needed to prevent this type of incident in the future.
Death Caused by Compounding Error
The medication the child was taking for his sleep disorder needed to be prepared by his pharmacy as an oral suspension. For a year and a half, his family had been filling their prescriptions at the same place, so what seemed absolutely routine ended in tragedy simply because the person preparing the suspension reached for the wrong ingredient.
The Chicago Tribune published disturbing results from an investigation where reporters attempted to fill prescriptions that had known drug interactions with one another. On numerous occasions, the reports received prescriptions that would have combined to have serious and potentially deadly reactions, proving that there needs to be more oversight involved in the process of filling these scripts. When pharmacies allow errors like this to slip through their fingers, they may be held liable for failing to verify the prescriptions with patients’ doctors to make sure that they are safe when taken with one another.
More than Half of Pharmacies Tested Failed
In an effort to gather information from a substantial sample size, reporters selected 255 different pharmacies throughout Chicago to see whether pharmacists would detect the potential drug interactions. An example of a test was presenting prescriptions for two medications that were completely safe on their own, but would cause the muscles to breakdown and for patients to suffer renal failure— which could lead to death.
Of all the reasons cited for medication and prescription errors, illegible prescriptions seem to be the most inexcusable. There is no reason that pharmacists should not take the time to contact doctors and confirm their intentions prior to filling a prescription if the doctor’s handwriting is not legible. Unfortunately, many pharmacists assume that they know what is written on the prescription and dispense the wrong medications despite the very best of intentions. New technology is now allowing both doctors and pharmacies to verify prescriptions in an effective and efficient manner so that there is no longer any need for guesswork.
Handwriting is a Major Factor in Pharmaceutical Errors
Doctors must write many prescriptions for their patients on a regular basis and may scribble their prescriptions in haste due to the limited amount of time they have to give each patient under their care. Whether it is the intended dosage or the intended medication itself, it is very easy for pharmacists to mistranslate illegible handwriting when filling a prescription and the easiest way to remedy this issue is to simply contact the doctor and obtain verbal confirmation of the prescription.
The consequences of a person receiving the wrong medication or the wrong instructions when they have their prescriptions filled at a pharmacy can be deadly. A nationwide study conducted through the Auburn University in Alabama found that 2 out of 100 prescriptions have errors, either in the content or in the labeling. This can attribute to over 60 million prescription errors each year in the U.S, many of which can be prevented.
Common Causes For Errors
There are many different reasons that these prescription errors happen, from plain human error to equipment. In the Auburn University study, they looked at several factors and found correlation between certain circumstances that seemed to attribute to both the error rate and the rate that errors were detected.