Understanding the Prescription Drug’s Path through a Pharmacy can Reduce Error

In a recent study that our Maryland Pharmacy Error Attorneys have been following, USA Today investigated every step of a prescription’s path in a pharmacy—to uncover the potential for medication mistakes with each step of the filling process, that can lead to patient injury or wrongful death.

In the research, USA Today interviewed pharmacy experts and toured two pharmacies, a CVS and Walgreens, to study the six steps of the prescription filling process, and the potential errors that can happen along the way, as well as real cases that have caused actual injuries or death.

Step 1: Prescription received

When the customer drops off the prescription to the technician, or the doctor’s office calls in the prescription, errors can occur if a technician misunderstands a doctor’s handwriting, prescription codes and abbreviations or misunderstands the oral instructions over the phone. In one case, a doctor’s prescription for methadone read “sig 4 tablet BID for chronic pain,” which means “Please label (sig) this drug to say: take 4 tablets twice per day (BID) for chronic pain. The technician typed, “Take 4 tables by mouth as needed for chronic pain.” The patient allegedly died of an overdose of methadone.

Step 2: Prescription entry
A technician then scans the original prescription into the computer and manually enters the patient’s personal data, like name, address, date of birth and phone number, as well as drug information, strength, dosage instructions and quantity. If a technician incorrectly types the prescribed drug dosage, formulation or the patient’s medical condition, history or allergies into the computer, then serious errors can occur, including personal injury. Also if the wrong drug code is chosen in the computer system, it can be mistaken for a similarly named drug. In one instance, a pharmacy was asked to fill a prescription for compazine, an anti-nausea drug, (COM) and accidentally gave the patient a generic substitute for coumadin, a blood thinner (COU).


Step 3: First verification

The pharmacist checks the scanned original prescription against pharmacy data, to make sure that all of the information about the patient, like the name and date of birth match. The pharmacist then checks the drug, quantity, dosage directions and strength to make sure they are correct. Pharmacists sometimes don’t spot the technician’s errors in the original entry of a prescription.

Step 4: Filling the prescriptions

A technician then takes medication from the drug storage shelves and matches the Identification number with the prescribed drug. The technician also scans the bar code on the bottle and the information sheet to make sure they are an exact match. A label is printed out, and the technician counts out the pills, fills the vials and puts the prescription into baskets that are coded by color—for immediate patient pick up or later. Pharmacy error can often happen if the technician selects the wrong drug, or the right drug with the wrong strength—as the drugs are often stored near drugs with similar names and can be confused with other drugs that are similarly named. In one case, a child’s prescription for Zyrtec, an antihistamine, was misfiled with Zantac, a drug to control stomach acid.

Step 5: Final verification

The pharmacist checks the patient’s name, number of the prescription, and all other information in the computer against the original prescription, as well as taking a scan of the bar code on the bottle and comparing the photo of the pill in the computer with the actual medication. The pharmacist also double checks for any potential allergies or drug interactions with other medications. Errors are made in this final verification if the pharmacist doesn’t find the error made between the prescribed drug and the medication chosen, or if the pharmacist neglects to check the bottle’s contents.

Step 6: Completing the sale

The cashier on duty, often an entry-level technician, rings up the sale and then asks if the patient would like to talk to the pharmacist about the drug’s purpose, instructions, and possible side effects. Errors are possible here when the pharmacist doesn’t automatically provide medication counseling when the prescriptions are picked up.

In a related blog, our pharmacy misfill attorneys discussed the importance of getting to know your pharmacists—and how the discussion of your current drugs, dosages, and interactions can help prevent pharmacy misfills, mistakes, and possibly prevent personal injury.

If you or someone you know has been injured by a pharmacy mistake or misfill in Maryland or the Washington, D.C. area, contact the attorneys at Lebowitz and Mzhen, LLC for a free consultation.

Prescription Errors: A Prescription’s Path Through a Pharmacy, USA Today

Related Web Resources:

American Pharmacists Association: APhM, American Pharmacists Month 2009

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