Reprinted from the July 2007 Nevada State Board of Pharmacy Newsletter.
Due to a recent inquiry by a national news division, we were asked to tally serious patient injuries and/or deaths reported to the Nevada State Board of Pharmacy that were the result of prescriptions being incorrectly filled in retail/community pharmacies in Nevada. Since this issue has been an ongoing concern of the Board, and to heighten awareness of how devastating to both the patient and the pharmacist it may be, we would like to share the data. The following reflects complaints to the Board regarding incorrectly filled prescriptions from the year 2000 to the present:
1. Number of complaints: 63
2. Number of those 63 that resulted in serious consequences: 20
3. Number of those 63 that contributed to the death of the patient: 5
All of the above complaints were investigated and were brought to a full hearing before the Board. In every case, discipline was imposed against both the pharmacist and the pharmacy involved.
To share some insight on how and why these errors are committed, note the following:1. Virtually all errors we see are the result of incorrect input of the prescription by the technician (or clerk, when clerks were allowed to input) and were not caught by the pharmacist.
2. Many errors are the result of picking the wrong medication on a “drop-down” screen. This is especially prevalent with “sound-alike” drugs.
3. Some errors were the result of the technician or pharmacist pulling the wrong drug from the shelf prior to input, and populating the drug field by typing in the national drug code from, or scanning, the bottle that was pulled (and is incorrect). Obviously, if you scan the incorrect bottle at the front end, it will match at the verification end.
4. Often, pharmacists are filling and verifying against the label, rather than the hard copy of the prescription or a scanned image. Some of the scanned images are so poor that verification is difficult. Not looking at a good image or the real prescription is extremely dangerous.
5. The majority of these errors could and should have been caught during patient counseling. We remind you that Nevada law requires the pharmacist to counsel (not make an offer to counsel) and requires the pharmacist to document that counseling with a handwritten signature or initials. When we see a tricyclic antidepressant (clomipramine) go out to a patient who was supposed to get a fertility drug (clomiphene) we must really question the counseling.
Another interesting situation that Board staff is frequently encountering is that of a pharmacist being wrongly accused of misfilling a prescription that he or she had absolutely nothing to do with because his or her computer-generated initials appear on the label. We wonder how and why this happens so often and can only ascertain that pharmacists are logging in on a particular terminal, then leaving it open to whoever happens by and goes to work on it. We have more than one case where a pharmacist has been accused of misfilling a prescription that was filled after he or she had left for the day! You must all be vigilant about protecting your passwords and most certainly the terminal at which you are logged on.