Archive for category Pharmacy Errors

Discharge Drug Errors — 50% mistakes

manymedsMedication mistakes are common.  A recent study by Amanda Mixon following discharge from the hospital pegs the error rate at an astounding 50%.  The study focused on whether instructions given to patients at the time of discharge from the hospital matched what the patient later took at home.

The study is  biased by assuming all the errors are caused by patients — not the providers.  The authors point to patient problems of low health literacy and a poor facility with numbers.  Illegible instructions, poor communication skills, excessive complexity of medical regimens,  conflicting instructions, and giving verbal instructions to the wrong person are all provider or institutional issues.

Even a simple phone  call after discharge might have cleared up patient confusion — perhaps the study would have been better with a phone call and no phone call comparison.

The article conclusion is to apply more effort to find those high risk patients.  Another conclusion would be to find those high risk hospitals having difficulty telling patients what drugs to take.  The study was done at a VA facility affiliated with Vanderbilt — a good place to start the search.

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Clinic Pharmacist — great idea

Pharamcist pictureWow — a pharmacist called me before a visit with a new doctor to review my medications.  What a great idea.

This clinic has a pharmacist on staff to discuss medication issues with patients.  And, that pharmacist calls all new patients to review ongoing medications, record them in the medical record and make recommendations that the new doctor will review at the upcoming visit.   Recommendations like problems with drug interactions, newly available generics, less expensive alternatives and contraindications.

That same pharmacist arranges refills and responds to drug questions on the clinic Internet Portal.

What a great service.  Discussion of medications by physicians is usually too brief.  And, any input from the pharmacist is usually after the fact so physicians are not too happy to call the patient and admit a problem with prescriptions they just wrote.

Sometimes great ideas just need a SHOUT-OUT. This idea is super — an actual partnership between a prescriber and a pharmacist.

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Errors at the Pharmacy — what is that pill?


Assume you just picked up your prescription for pills at the pharmacy.  The bottle has a label with a drug name, dose and how often to take it.  But, is the pill the right one, the one the doctor had in mind?  Or did somebody make a mistake and put the wrong little green pills in your bottle?  Or perhaps the bottle has the wrong label?  Did you actually get the pills Dr. Jekel prescribed for Mr. Hyde?  Just to keep this in perspective the picture above is of the same medication: losartan;  made in different strengths and by different manufacturers.  Pharmacists do their best to keep the pills straight but they are only human.

To err is human.  But, in most medical situations the goal is an error rate better than 1 in a million.

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The rate of uncorrected pharmacy errors is much worse:


The estimate of errors varies widely, see the article by James et al.  The 1 error in 33 prescriptions (3%) is an overall estimate of  errors (like the wrong directions on the bottle).  An article by Flynn et all notes “An estimated 51.5 million errors occur during the filling of 3 billion prescriptions each year.”  Death resulting from these errors is unlikely but still is reported.  In everyday terms a local pharmacy will make dispensing errors several times a day.  Large automated pharmacies actually do much better, sometimes in the range of 1 error in 100,000 prescriptions — not too bad but still not good enough.

What can the prescriber do?

  • Always discuss prescribed medications with the patient
  • Tell the patient why each medication is needed
  • Give the patient a complete list of medications and
    indicate which are new, changed, or just continued
  • Send prescriptions electronically

What can the patient do?

  • At the prescriber office or when leaving the hospital
    • Get a complete medication list (or make a list yourself)
    • Record why you take each medication
    • Understand if the medication is scheduled
    • or just taken as-needed for some symptom
    • Record the drug name, dose and how often to take
    • Are you getting enough refills to last until next visit?
    • Ask what the top 3 side effects might be (printed list of a zillion possible side effects is nearly worthless)
  • At the pharmacy, before paying for the medication:
    • Look at the medication bottles and verify
      • Your name
      • The prescribers name
      • Drug name, dose, how often to take
      • Confirm this medication is for your known diagnosis –“this one is for my high blood pressure, right?”
      • Is the quantity and number of refills correct?
    • Ask to look at the pills themselves
      • If this is a refill the pill should look the same as before
        • if not, why not?
    • Did all the prescriptions the doctor prescribe get filled?
    • If you are getting a new medication always allow the pharmacist to talk to you about the medication
    • If the medication is an inhaler ask for instructions and a demonstration
    • If the medication is an injection ask for instructions
    • If the medication is a liquid ask how to measure it
    • If the medication costs $100 a dose or more you have a right to know where it was made and what precautions were taken to avoid counterfeit medications.
  • At home
    • Read the information you were given about the medications
    • ID your pills with an online pill identifier like
    • If you find errors, obviously, contact the pharmacy immediately
    • Report medication errors to the ISMP (Institute for Safe Medication Practices) or if severe to the state pharmacy board.
    • Report pharmacy errors to your prescriber

If you have experienced errors or have other suggestions to avoid errors please leave a comment.

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