WRAL Investigates

'How could this have happened?' WRAL investigates pharmacy errors

Posted January 30, 2014
Updated January 31, 2014

— Pharmacies in the U.S. make about 51 million errors a year, according to a Pharmacy Times study, but not everyone checks their prescriptions to make sure they are correct.

One of those errors affected a Wake County woman, who noticed that she received different sized pills for her dog, which requires medication for seizures. Elizabeth Delaney says she wants other customers to check their prescriptions and make sure the pills in the bottle match the description on the label.

Delaney went to CVS, at 3581 Davis Drive in Cary, to get phenobarbital for her 8-year-old dog, Luna, which needs the medication twice a day to control the seizures. She says she opened the bottle to find two different sized pills. Twenty of the pills were the correct dosage – 65 milligrams – but 100 of the pills were 97 milligrams and too strong for Luna.

“How could this have happened? How can you do that? Where’s the quality control in the system there? Why wasn’t someone else counting behind (the pharmacist)?” Delaney said, adding that she called the pharmacist to report the error. “She just said she was in a rush and that she was sorry.”

CVS refunded Delaney's money and replaced the prescription with the correct dosage. In a statement to WRAL Investigates, the business said: "We apologized to Ms. Delaney and corrected the prescription as soon as this incident was brought to our attention. We are committed to continually improving quality measures to help ensure that prescriptions are dispensed safely and accurately."

Jay Campbell is executive director of the North Carolina Board of Pharmacy, which sets the rules for pharmacists and has a team of investigators that look into complaints. His team verified about 350 prescription mistakes over the past five years in North Carolina.

  • 87 in 2009
  • 75 in 2010
  • 68 in 2011
  • 70 in 2012
  • 46 in 2013

Campbell says those numbers only represent the people who noticed a problem and filed a complaint, which doesn't always happen.

“I would encourage folks who have a dispensing problem to contact the board as well as the pharmacy, not out of a punitive standpoint … but it’s helpful for the board to know if this is an isolated incident with respect to the pharmacy or pharmacists, or (if) this the latest incident in a pattern of incidents,” he said.

Last year, the pharmacy board uncovered multiple dispensing problems at Faulkner’s Drugs in Monroe in Union County, including a morphine prescription that was four times stronger than it should have been. The elderly patient ended up in the hospital. Two drug store employees – pharmacist Joseph Black and pharmacist-manager David Jamison – had their licenses suspended, and the pharmacy received a reprimand.

“Patient safety needs to be the first priority, the second priority (and) the third priority,” Campbell said.

Luckily for Delaney, she noticed the pharmacy mistake before giving Luna what would have amounted to an extra dose of medicine a day. She says she hopes her close call is a wake-up call to patients and pharmacists.

“She’s just a dog to some people. To me, I love my dogs so much they even have a trust fund,” Delaney said. “A pharmacist is a trusted individual, like a doctor is. In some ways, they have your life in their hands, and to say that you’re in a rush is not good enough.”

WRAL Health Team physician Dr. Allen Mask suggests customers get to know their pharmacists and take time to talk with them about prescriptions, especially the first time filling a prescription.

“Amazingly, it’s estimated 80 percent of dispensing errors are caught at that point, because the pharmacist is supposed to show you the label and the pills,” Mask said. “And, of course, if you don’t take the time to talk to the pharmacist, there’s an easy way for patients to protect themselves. Every prescription bottle or packaging includes a physical description of the pill, including the number imprinted on it. Once you get home, compare the two to make sure everything matches.”

36 Comments

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  • Jenna Moore Feb 10, 2014

    I wonder how many of these errors could be avoided if pharmacies would stop trying to cut costs. Most pharmacies employ mostly pharmacy techs, who have very little of any training. There might be one pharmacist available at a time. Then the pharmacies that are inside groceries stores and such frequently have only one person in the pharmacy at a time. How is one person supposed to count the pills, answer the phone, and address customers at the counter all at the same time?

  • blackdawg47 Feb 4, 2014

    Great Story!! For those who are not already aware, phenobarbitol IS a human drug that is also used for seizures in animals and has been for years. Many pet owners purchase this drug at a drug store rather than from their Vet because the Vet charges 5x more for it. In this case, the label on the bottle had a name on it (not "Pet") so the person filling the prescription wouldn't have known who the patient was. It shouldn't and doesn't matter if it were for a human or a pet - a heartbeat is a heartbeat - and to jeopardize the life or health of another because you're "in a rush", especially in that profession (or any trusted medical profession for that matter), is obviously not good practice at all, period. Let's not forget the main point of this story: to hopefully increase our awareness and to pay more attention as we're all living such busy lives nowadays! It could save your own life, your elderly parents, and yes - your pets too! I know I'm going to pay attention from now on!

  • LastSon1981 Feb 4, 2014

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    I agree its like a human made a mistake that could have been avioded by opening the bottle and saying some of these pills dont look right. LETS CRUCIFY THEM!!!!!!! The complaints should be about the cost.

  • Obamacare prevails again Jan 31, 2014

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    Now that is scary. Imagine a part time employee with an after school job mandated my mommy and daddy not caring how many or what goes in each bottle.

  • smcallah Jan 31, 2014

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    Is there a such thing as a Pharmacy tech now? When I worked at Kerr Drug on Lake Boone Trail around 1992 or so, I was just a regular part time employee and sometimes filled prescription bottles behind the pharmacy counter when they were backed up. I also was afraid of screwing up, so I triple checked that I was putting the right pills in the bottle and counting them correctly.

  • Obamacare prevails again Jan 31, 2014

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    I agree.......it's not the 1950s anymore.

  • ForHim Jan 31, 2014

    Get to know your pharmacist??? Ha. What a joke. After standing in line for 30 mins to drop off or pick up a script, who has time to talk to the pharmacist? Not to mention every time we go in, there are different people working. We go to Walgreens. Would love to go elsewhere but they are all the same. Like herding cattle in and out of there.

  • girlwonders Jan 31, 2014

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    A prescription for your dog costs 5 times as much at the Vet as it does at the pharmacy. That's why we buy our pet meds at the pharmacy.

  • Dr Sanchez Jan 31, 2014

    WRAL should just start calling their "Investigative" reports "I looked online at wikipedia"

    You won't be winning any regional emmy's for this report. Good grief. This is like Monica Laliberte's "investiagtions" where all she does is check the restaurant inspections and read them to the viewers or you guys show us a new consumers report byte.

  • sinenomine Jan 31, 2014

    While it is not the subject matter of this report remember that doctors slip up too.

    I have a close friend of forty years who owns a pharmacy in western North Carolina. Some years back she refused to fill a prescription because she recognized that, due to the doctor's error, the dosage would likely have proven fatal to the patient. When she finally got the doctor on the phone, having run the gamut of his protective staff, his quiet three word response when she told him what he had done was "Oh my God".

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