'How could this have happened?' WRAL investigates pharmacy errors
Posted January 30, 2014
Updated January 31, 2014
Cary, N.C. — 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.”