Channel 2 Investigates reveals pharmacies with most complaints about prescription errors
The number of complaints filed has nothing to do with the number of mis-fills that actually occur. Unless prescribers or pts file complaints with the state Board of Pharmacy… it is just “swept under the rug”..
HOUSTON – Channel 2 Investigates is revealing the local pharmacies with the most complaints about prescription errors.
Many mistakes never get reported, and there are steps you can take to prevent a dangerous mixup.
“He’s had a rough several months of life,” said Evan’s mother, Krisztina. “He’s kind of hit every bump in the road.”
Merritt was born with a serious kidney condition. He’s already had one surgery and a second surgery is just weeks away.
“He was placed on a maintenance antibiotic from birth,” Krisztina said.
In October, Merritt’s doctor prescribed a new antibiotic.
“We gave him that antibiotic every day for 30 days,” Krisztina said.
When it was time to refill the prescription, Krisztina claims something was off.
“The two medicines looked so different,” Krisztina said.
Merritt’s dad went back to the pharmacy to check it out.
“The pharmacy tech was shocked,” Krisztina said.
Merritt’s parents think the new prescription was right, but what he had taken every day for the previous month was wrong.
“It was terrifying,” Krisztina said. “I didn’t know if it was a medication with long-term implications on his health. I still don’t know that.”
The family contacted CVS and, “We then filed a complaint with the Texas State Board of Pharmacy Licensing,” Krisztina said.
CVS said, “We fully investigated Ms. Merritt’s complaint last fall and determined that her child’s prescription was filled correctly. A thorough review of the safety procedures during the filling of the prescription in question found that all steps were performed correctly and no error was made. We informed Ms. Merritt of our findings in November.”
The case is not closed yet. The State Pharmacy Board is still investigating.
For months, Channel 2 Investigates poured through complaints about prescription errors.
By law, pharmacies are not required to report complaints. Most of the time, complaints come voluntarily from doctors or patients.
The CVS pharmacy on the 9500 block of Broadway in Pearland had the most complaints in our area — five since 2010.
The Walgreens on the 6800 block of South Fry road in Katy received four complaints.
“We see, it’s a wide range,” said Allison Vordenbaumen Benz, R.Ph., M.S., director of professional services with the Texas State Board of Pharmacy. “All the way from something that involves a miscount. If the patient was supposed to receive 30 tablets and they only received 28. They might have the wrong directions for use on the prescription label, they might have a situation where one patient gets another patient’s prescription or it’s the wrong drug, or it’s the right drug but the wrong strength.”
While a miscount might sound insignificant, mistakes like this can be deadly.
“Fortunately, that does not happen very often,” Benz said.
Channel 2 Investigates also found three complaints filed against the CVS on the 3800 block of Old Spanish Trail. In one case, the patient was “bedridden and experiencing end-stage liver failure.”
After receiving the wrong medicine, the patient became “non-responsive” and was hospitalized for 15 days.
The pharmacy is now on a two-year probation.
Board action can range from a warning letter to losing a license.
View Document: Dispensing Error Guidelines
So how can you help prevent pharmacy mistakes?
1. Talk to your pharmacist. Ask the pharmacist to look at the drug and dosage before you leave.
2. Look at the insert that comes with the medication. Compare the shape, size, markings and color of the medicine before you take it.
“Never, ever take it for granted that the prescription you fill and pick up is exactly what you think it is,” Krisztina said.
CVS also told Channel 2 Investigates “Errors are very rare, but when they happen we investigate to determine how it occurred as part of our process of continual improvement.”
When you discover a problem, it’s important to file a complaint, which you can do here.
CVS’s complete statement:
“The health and well-being of our patients is our number one priority. Our pharmacists follow comprehensive quality assurance processes to ensure prescription safety and accuracy. Every prescription dispensed at CVS Pharmacy undergoes a multi-step review by a pharmacist prior to being dispensed to a patient.
We fully investigated Ms. Merritt’s complaint last fall and determined that her child’s prescription was filled correctly. A thorough review of the safety procedures during the filling of the prescription in question found that all steps were performed correctly and no error was made. We informed Ms. Merritt of our findings in November. In addition, we resolved the complaint concerning the 4-year old incident that occurred at our Old Spanish Trail pharmacy with the Board of Pharmacy back in 2014 and took corrective action with the pharmacy.
As a health care company that strives to help people on their path to better health, we seek out new technology and innovations to enhance safety, we engage with industry experts for independent evaluations of our systems, and we are committed to continually improving our processes to help ensure that prescriptions are dispensed safely and accurately.
Prescription errors are a very rare occurrence, but when they happen we do everything we can to take care of the patient’s needs, including contacting their prescriber to address any health concerns. In addition, we require our pharmacies to report such events to the company’s patient safety organization as part of our program to learn from these incidents and continuously improve quality and patient safety.”
Walgreen’s complete statement:
“The four complaints at the store inquired about occurred between 2008 and 2011. In two of those cases the Texas State Board of Pharmacy concluded its investigation by dismissing the complaints with no disciplinary action taken. With all prescriptions filled in our pharmacy, our first concern is always the patient’s well-being. We take this issue very seriously and have a multi-step prescription filling process with numerous safety checks in each step to reduce the chance of human error. In the event an error occurs, we investigate what happened and work to prevent it from happening again.”
Filed under: General Problems
The tacit message here is that every mistake, no matter how seemingly trivial, must be reported; the must be changed to require mandatory reporting. The folks who are calling for this have good intentions, but they have no idea concerning the realities of the Universe that exists behind the counter. Let’s look at a couple of the practical considerations against the status quo.
They have no clue as to the paucity of resources that most BOP have available to them presently. It can take years for a complaint to come to full resolution in some states. Mandate error reporting and most folks would die from old age before their prescription error killed them and before the BOP would have time to investigate, arrive at a finding(s) and then execute judgement based on the finding(s). The public requires and deserves timely resolution.
Most BOP are funded by the license renewal fees of the various and sundry classes of licensees under the BOP authority. Do I relish the idea of renewal fee being increased by a factor of 5 to 10 times to generate the kind of revenue that the BOP would need to expand the investigative and enforcement staff to cover this? Would the fee increase be that much? Potentially. The state legislature in most states does not have the annual surpluses to fulfill the increase in budget request that would be in the tens of millions of dollars in the smaller states.
Pharmacists and Pharmacy techs are human beings. We make mistakes, albeit very few in light of the number of prescriptions that we touch on a daily basis. In spite of the objections that I threw out, I’m not wholly opposed to the idea of some sort of error monitoring system, but with one proviso, Right now, with the exception of the state of Oregon (there could be others, but I’m not presently aware of them), when the BOP disciplines a license for this kind of thing, there has to be a human being attached to it. Nevermind that the mega chain employing the pharmacist or pharmacy tech has real, demonstrable culpability in creating the error in the first place. How?
By demanding certain minimum levels of revenue generating metrics that create a work environment where the workload substantially increases the risk of dispensing errors is the primary mechanism where the chains are concerned. Nevermind the distractions from such environments that are problematic. Nevermind that the staffing is reduced in order to cut payroll expenses, resulting in more multi-tasking that some are better at than others or that the metrics that determine labor hours are not realistic in the kinds of considerations not made, like the location of the pharmacy, the number of prescribers in the immediate vicinity, the lack of competition in an area, the demographics of the patients/customers in an area.
I realize that I’m being rather vague here, but for the lack of appropriateness in breaking down and detailing what I’m referring to in a space like this. Please understand that these kinds of things can result in extremely high demand periods on certain days at certain hours in the course of a month that are not entirely predictable and then relatively slower, but still busy in between times that fill the rest of the day. Many of the high demand time patients require that they wait while their meds are filled due to various circumstances. The pressure to fill a hundred prescriptions in an hour or less with just two pharmacists and their techs, plus maybe clerk on the register and helping on the phones is not unheard of. The phone keeps ringing, the walk-ups need to ask about cough medicine, the wholesaler driver needs a pharmacist to count the CII’s in the delivered order and then sign for them.
The metrics don’t look at this kind of dynamic. Total numbers for a day, a week, a month, a quarter and a year are all that’s considered. So, if mandatory error reporting is required, then the BOPs have to have the latitude to go after the chain, the management in the chain and anyone within the organization that contributes to the kinds of environments the push a human being past their limits in order to produce more Greenbacks Almighty.
If the end game is really about patient safety, then the “Guardians of Patient Safety” have to be able to go and be willing to go after the higher ups in the chain of command. Going after the Lieutenants and the NCO’s as before will result in nothing but a shortage of people behind the counter and more risk. The General Staff has to be held accountable, the Majors, the Colonels, the Generals and Field Marshals, i.e., those at the top of the chain of command have to be held accountable if there is to be any meaningful changes seen.