PHARMACIST STEVE

According to the court, a patient was discharged from a hospital, and a nurse phoned prescriptions to the patient’s pharmacy. The prescriptions were received by a pharmacy technician who had no formal training and had worked in the floral department before being transferred to the pharmacy.

The technician made many errors transcribing the prescriptions. The most significant was confusing once-daily methotrexate for the metolazone that had been prescribed. The pharmacist approved the once-daily methotrexate, later explaining “for some reason I didn’t recognize the weekly versus daily. It didn’t click in my mind.” The pharmacy’s computer system did not flag the once-daily methotrexate dosing schedule.

The patient’s husband picked up the medication. He was asked if he had any questions, to which he replied no. No additional patient education was provided. The patient used the methotrexate daily as instructed on the label, and she died less than 1 month later from the effects of the drug.

A lawsuit was filed against the pharmacy. The pharmacy admitted negligence, and the jury returned a verdict for the plaintiffs in the amount of $2 million. This was reduced to $125,000 based on statutory damages caps. The plaintiffs claimed additional damages for “aggravating circumstances,” but the lower court granted a pharmacy motion to deny these damages.

From this ruling, the plaintiffs appealed.

In reversing the lower court, the Missouri Court of Appeals cited four factors that would support an award of additional damages based on aggravating factors.

First, the court noted that in the absence of a computerized “hard stop” for once-daily methotrexate prescriptions, it is imperative that pharmacists conduct their own personal verification of prescriptions. A pharmacy corporate representative testified that, based on her analysis of the facts, “the pharmacist really did not perform a medication review of this drug and of this patient.” The court was skeptical of the pharmacist’s claim that he had reviewed the prescription and concluded that the failure to perform such a review could justify a finding of aggravating circumstances.

Second, the court was critical of the pharmacy technician receiving a new prescription over the telephone. Although the court cited evidence that Missouri is one of only a few states allowing this practice, the court noted the pharmacy’s own policies and procedures that state only pharmacists are allowed to accept prescriptions over the phone.

Third, the court was critical of the pharmacy’s failure to provide patient education when dispensing a high-risk medication like methotrexate. An expert witness for the plaintiffs testified that simply asking if the person receiving a medication has any questions is inadequate. He testified that it is “absolutely inadequate and absolutely deadly in the case of high-alert drugs to not do that counseling.”

Fourth, the court noted that the pharmacy “had made no meaningful changes to its procedures as a result of [the patient’s] death.” The pharmacy corporate representative testified that the pharmacists as a group “have had an in-depth conversation about being more conscientious than we already were, you know, just trying to be more safe in everything that we do.” The court was not impressed.

For these reasons, the appellate court reversed the lower court’s dismissal of the aggravating circumstances claim.

This case is a classic example of how pharmacists can be set up to fail by a dysfunctional system. This error did not occur because pharmacists weren’t conscientious and weren’t trying to be safe. Remedial measures after a fatal error of this type must go beyond a platitudinous pep talk.

Computer systems must be designed to implement a “hard stop” when a lethal prescription is entered into the pharmacy computer. Pharmacy technicians must be adequately trained and forbidden to perform functions for which they are unqualified. Patient counseling is absolutely mandatory when dispensing a high-alert drug to a patient for the first time.