Do Pharmacists Fill Prescriptions Incorrectly?

The concern over pharmacist errors is a valid one, given that seemingly simple tasks can take a wrong turn and undermine patient safety. Indeed, pharmacists, like doctors, plumbers, and carpenters, are human and capable of making mistakes. However, the frequency of such occurrences and the measures taken to ensure accuracy provide a nuanced perspective.

The Prevalence of Mistakes

While it's unfortunate but true that pharmacists sometimes fill prescriptions incorrectly, the frequency of such incidents is relatively low. According to various reports and individual experiences, approximately 10% of prescribed medications might be filled improperly, often involving aspects like prescription strength, count, or even the correct medication.
For instance, one common issue is the miscoloring of drugs. A prime example of this is when a patient is prescribed a medication containing blue dye for an allergy, yet receives the same medication filled with blue tablets. These instances can be particularly frustrating, as highlighted by the following personal experience:

"Approximately 90% of the time, one of my renewable prescriptions is filled with 'blue' tablets despite a known allergy to blue dye. The pharmacy CVS has a note in my file that confirms this." —Patient's Experience

Variety of Mistakes

The reasons for prescription errors can vary. They might include:

Missing Doses: Some pharmacists might inadvertently short the patient by a few tablets, leading to incomplete treatment. Wrong Medication: This includes giving the wrong dosage form (e.g., giving fioracet instead of fioranal) or the incorrect medication altogether. Improper Splitting: Time-release tablets are often mis-divided, altering their efficacy. Label Errors: Mislabeling of the medication can lead to confusion and incorrect dosage.

Consider one such case where:

"The pharmacist at a CVS filled a prescription for fioranal, a medication containing aspirin, when the actual prescription for fioracet, which contains acetaminophen, was issued. This error could have led to a dangerously high dose of acetaminophen for my husband, who already takes medication containing this substance."

Preventive Measures and Safeguards

Pharmacies and pharmacists implement rigorous checks and balances to ensure the accuracy of prescriptions. Typically, a pharmacy technician or a pill counter fills an order. The prescription then goes through a series of verification steps to catch any discrepancies before being handed to the pharmacist. This entire process is designed to minimize the risk of errors:

Technician Filling: The initial filling is done by a trained technician who accurately counts and dispenses the correct drug. Pharmacist Verification: The pharmacist then opens the prescription, visually checks the tablets or capsules, and verifies that the markings and other details match the prescription. Chain of Custody: Once verified, the prescription moves to the final stage where it is ready for the patient to collect. This step ensures immediate intervention if any error is detected.

Additionally, if a patient notices any discrepancies, they are advised to contact the pharmacy immediately. In cases where errors are recognized, the patient is instructed not to consume the medication and to return the prescription for immediate correction.

Conclusion

While the occasional mistake by a pharmacist is a genuine concern, the healthcare industry has various measures in place to ensure the highest level of accuracy. Patients should trust the trained professionals and take every precaution, such as verifying the medication and dosage before consumption.

Keywords

pharmacist mistakes prescription errors prescription accuracy