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U.S. Pharmacy Errors: Unreported Epidemic?

March 29, 2007 11:40 AM

Alex_pharmacy_nr Walgreens never told federal or state authorities that one of its pharmacists had made a mistake on a prescription that led to devastating brain damage in a suburban Chicago infant.

Because it didn't have to. 

Neither the federal government nor 46 of the 50 states have any law requiring that drug stores report prescription errors, even in cases involving serious injury or death.

See Pharmacy Errors in Pictures.

While some fear there is an unreported epidemic of pharmacy errors, there are no reliable figures to gauge the scope of the problem. And that's the way the industry seems to like it.

"I don't think it should be publicized," said Mary Ann Wagner, the senior vice president of the National Association of Chain Drug Stores, in an interview to be broadcast Friday on "20/20."

Click Here for Full Blotter Coverage.

She says the industry fears the public won't understand the difference between minor and major errors, and that the figures could be used to punish drug stores.

In the suburban Chicago case, the pharmacist mistakenly put a medicine for adult diabetes in filling a Phenobarbital prescription for seven-month-old Alexandra Gehrke.

Alexandra's mother, Tracey Gehrke, says the medicine was intended as a precaution against seizures in her prematurely-born daughter but actually triggered severe seizures.

"I was poisoning my baby, and I didn't know it," she told "20/20."

A jury ordered Walgreens to pay the family $21 million in damages, but the Gehrkes say neither the company nor the pharmacist ever offered an apology for a mistake that forever altered their daughter's life.

Alexandra cannot walk, talk or feed herself, although she is expected to have a normal life expectancy.

"You hurt people, and you don't apologize?" Tracey Gehrke asked.

The pharmacist who admitted responsibility for the error, William Zaeske, continues to work at Walgreens and is now a pharmacy manager at another store near the one where the prescription error happened.   

Zaeske declined to answer questions from "20/20" about how the error occurred.

In a statement, Walgreens said, "We deeply regret the few errors that have occurred among the more than 500 million prescriptions we fill each year at our 5,600 pharmacies."

As the country's biggest pharmacy chain, Walgreens recently reported record profits.   

It says it has invested nearly $1 billion in "redundant pharmacy safety systems" and training over the last 10 years.

For the full investigation, watch "20/20" Friday at 10 p.m. EDT.

March 29, 2007 in Pharmacy Investigation | Permalink | User Comments (280)

User Comments

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Of course pharmacists make mistakes....they too are human! We need to develop a system that recognizes that humans make errors, and has a mechanism for checking work so that WHEN errors are made, they are recognized before patient harm takes place.

Posted by: Amy L. Friedman MD | Mar 29, 2007 12:34:32 PM

I know various people in different states, myself included, who've received erroneous perscriptions by Walgreen's pharmacists. No apologies were ever offered, and I personally was treated like it was somehow MY fault that they gave me the wrong medication! Luckily I caught their error before walking out the door; I can't imagine what would have happened... I have never shopped at Walgreens since. My heart goes out to the Gehrke family.

Posted by: J | Mar 29, 2007 1:03:56 PM

I had a similar experience at Walgreens in 2003 when my 4 year old was diagnosed with leukemia. The pharmacist reversed the dosage amounts of his dexamethasone and his mexotrethate. Luckily, I caught the error at home that night before I gave him the dosages since I had just spent the previous week in the hospital observing the medicines he was taking. Likewise, the pharmacist who made the mistake is still working at the Walgreens in Littleton, Colorado. I don't what the answer is, but this definately needs to be governed and there need to be swift and severe consequences when errors are made. At the very least the pharmacists need to be fired.

Posted by: Pamela Koster | Mar 29, 2007 1:05:23 PM

I want the Congress to create a law that requires all drug stores to report errors. In addition to that, these pharmacists should be held criminally liable for their behaviors that results in such damages to their customers's health.

Posted by: theA | Mar 29, 2007 1:09:27 PM

The biggest treat against the public these days out there are the pharmaceutical companies, but yet there are a bunch of idiots out there that can't understand this. Watch T.V. these days and you are barraged with parmaceutical commercials for this pain or for that other crap. Big Tabacco is nothing, nothing, compaired to these folks. Yeah, smoking is killing people, bull, legal drugs are killing people. Eliminate all pharmaceutical commercials and we'ed live a healthier life.

Posted by: ruben | Mar 29, 2007 1:11:42 PM

Mistakes are made in every profession in our society. However, when the mistakes are made in a health related area, their consequences are not usually made known to the public until they go to trials. Wlagreens' pharmacist made a critical mistake that basically destroyed a little girl's life. Their responsibility to this family is only 21 million dollars. This amount of money will not go far. Who will take care of the girl when her parents are no longer around? My suggestion is to have walgreens pay for all of Alexandra's healthcare expenses until she dies. At the very least, Walgreens should set up a trust fund for Alexandra. This might seem extreme and unfair to Walgreens until you think about how much Alexandra's parents are suffering mentally and physically everyday.

Posted by: Duy Nguyen | Mar 29, 2007 1:13:08 PM

This article certainly puts a one-sided spin on the issue. I'm not saying Pharmacists are innocent, but they face overwhelming numbers of prescriptions to fill each day. Errors are bound to occur. It is unfortunate that mistakes happen and people get hurt, and yes Walgreens should apologize. But, has anyone taken a survey on how many mistakes Pharmacists prevent? For example, how many times does a Doctor write a prescription for a drug that has an adverse side effect with another drug the patient is taking?

It is up to the Pharmacist to catch this mistake. Also, Pharmacists are overworked, and probably underpaid. I would argue that a Pharmacist is a more trusted profession than a Doctor, but we don't take care of them as we do the medical professions. How about enacting legislation that limits the numbers or hours a Pharmacists can work in a day. There is no limit now, and often they work for 12 hours at a time with no breaks. There are two sides to this story, let's be fair and tell both of them!

Posted by: Michael | Mar 29, 2007 1:18:52 PM

"I don't think it should be publicized," said Mary Ann Wagner, the senior vice president of the National Association of Chain Drug Stores.....She says the industry fears the public won't understand the difference between minor and major errors, and that the figures could be used to punish drug stores."


I think it should be made public. Our local pharmacy has made three errors in the last two years on just our Rx's. The wrong medication entirely. It was mislabeled. It had been prescribed for someone else. Another time they misread the script. Another time they, a chain which prides itself on catching interactions and advertises such, dispensed a med that could have overdosed and killed my son. I caught it myself, a meer customer peon that " wouldn't know the difference." I reported it to his MD as I didn't know who else to tell.
There is no such thing as a 'minor' med error.

Posted by: amy | Mar 29, 2007 1:18:55 PM

A Walgreens pharmacist in GA gave me the wrong medication. I had terrible side effects. When I told the pharmacist about his mistake he offered no apology. He simply said "It looked right." I was furious. At least acknowledge the mistake and apologize for it.

Posted by: Megan-Claire Chase | Mar 29, 2007 1:45:31 PM

Similar situation happened to my family but not as severe thankfully. Luckily my son wasn't injured in an error CVS pharmacy made early this year. I listened to a very old voice mail and heard a pharmacist message that the dose was wrong on the printed label. My son was already on day 10 of the antibiotic. He was supposed to have 3 teaspoons total per day. The label read 9 teaspoons total. I had to call poison control!

I had to call the Pharmacy and tell them never to leave an important message like that on someones voice mail. Then I called the doctor who was debating on doing tests on my son for kidney failure. It scared me to death! I thought I had just poisoned my son. Yes they should be reported and they should have to be watched carefully after an error like that. I neither got an apology just an excuse "well the pharmacist must have misunderstood the message from the doctors voice recording" but here's the kicker he also faxed the order plus called! Apparently that's when they realized they overdosed the script and left me the voice mail.

I told the pharmacy in the future never leave a message on someones voice mail and to make sure they contact and SPEAK with the parent. They had my home and cell number. Ther's NO EXCUSE for pharmacy errors.

Posted by: Toby Walsh | Mar 29, 2007 1:53:44 PM

This REALLY bothers me. To me, it means that pharmacists are now as poorly-trained and ignorant as the recent generation of physicians.

I expect pharmacists to KNOW the medications they dispense inside and out, just as I expect doctors to know that information. I expect pharmacists to know the major classes of drugs and what they are used for. I expect them to offer to discuss this information with the patient, and to ask a question or two to double check.

I'm not demanding that physicians or pharmacists be held to a higher standard; I'm asking that they be held to the standards I have for myself even as a patient. Okay, so I work in pharmacology (and previously worked in physiology) research. Okay, so I eat, breathe and excrete this stuff. But if I, with only a bachelor's degree, have to know and master this material, I think it's proper to expect others who may endanger lives with their ignorance of that material to know and master it as well. Furthermore, I know that the material is required for graduation from medical or pharmacy school. Is it so unreasonable to expect physicians and pharmacists to pay attention and remember what they learned? I think not.

Posted by: Lisa M | Mar 29, 2007 2:03:43 PM

Well I think that a family really needs a real break and that people need to realize that they can think that it won't happent to them but it really could and they won't know what hit them when they are shocked with it! I send my best wishes to the family especially to Mrs. Gehrke because she never got an appology for what the man did and he should of appologized for what he did was stupid and what if were to kill her then he might of really stoped to think that he should check the prescriptions before he did this! Good luck Alexandra I hope that in the future people will stop and think that they need to wake up at times!!! Kori Bielanin

Posted by: Kori Bielanin | Mar 29, 2007 2:24:03 PM

I am a recent graduate of pharmacy school. I work in a hospital now, but I worked retail pharmacy as a student from 2000-2006.

I see both sides of this issue..

First of all, for all of you who say you were treated poorly by the pharmacist after a mistake was made, I apologize. At the store I worked, we made a couple mistakes during my employment there (nothing serious, thankfully). We would typically refund the patient and apologize profusely.

There are typically a lot of safety measure in place and some of these errors may have been prevented if the pharmacist was thoroughly checking each prescription, HOWEVER...Let me explain a little what life behind a pharmacy counter is like. Often, there is only 1 pharmacist working (unless it is a big store). The technicians field the phone calls, work the register, get the meds off the shelf and count them, and label everything for the pharmacist to check. Meanwhile, the phone is ringing off the hook with people asking for the pharmacist (sometimes legit questions, other times it's a refill request that you don't need a pharmacist for), you have 2 patients at the counter with questions, you're on the phone with an insurance company trying to get a claim to go through, people ask how much longer it is going to be and watch you the entire time you're filling a prescription, and then you have to call the MD about a prescription that doesn't look right. Then you have to worry about the order and paperwork. You're expected to do all of this, properly verify 400 prescriptions, and remain friendly and personable. It's a very high stress situation, and errors unfortunately do go through.

Posted by: Kristen | Mar 29, 2007 2:47:43 PM

It's not just walgreens. I had it happen to me @ another pharmacy. A new generic for my Allergy med was actually a 5 day double antibotic. I had taken 37 of them b-4 I began to feel reason to question my doc. I then had to have blood work for liver and kidney damage. before that he had gave me the wrong drug for another script but I caught it because I knew what it was supposed to look like. When confronted, he just offered to fill it with the right prescription. I changed pharmacies.

Posted by: terri | Mar 29, 2007 3:06:50 PM

I to received the wrong perscription for my 7 yr old son from WALGREENS, It was for another patient with the same last name. It was for muscle and joint relief they said. I realized the error after going home and was about to give it to my son, I called them and they said they were extremely busy and would take a message and tac it to their message board, and I can expect to hear from them by tommorrow!!!

Posted by: Susan Bence | Mar 29, 2007 3:31:51 PM

I fully agree that errors need to be reported (all are required by law to be reported, but the info is not released to the general public). I also understand that people feel the need to blame pharmacists when things go wrong, but I'm assuming that most of you don't actually understand what it's like to work in a pharmacy. If your pharmacist is truly as bad as you claim, why don't you people report it to the PIC (pharmacist in charge) or the district manager?

Toby Walsh-you say that "pharmacists are now as poorly-trained and ignorant as the recent generation of physicians" and talk about your expertise in pharmacology, but do you really understand and know the drugs used today not just for their FDA-approved use but also for their off-label use that doctors prescribe for every day? I doubt it. When you truly understand the pressure that RETAIL pharmacists are under (thanks to corporations like Walgreens, Eckerds, and CVS) from managers who are not pharmacists, it is amazing that there aren't MORE medication errors.

Everyday we are expected to not only fill medications and counsel patients on their use (the whole reason that we went to school, by the way) but we also are expected to run a BUSINESS. Most pharmacists have no intrest in the business side of pharmacy- we want to serve our patients and give them the best care possible. But when you work for a corporation that expects you to fill 600 scripts a day with only one 30 minute break in your 12 hour shift, people are bound to get tired and make mistakes.

Posted by: Kathryn | Mar 29, 2007 4:18:10 PM

It is easy to shed bad light on any type of profession. Obviously newscasters can cut and chop interviews and distort facts in order to get the story they already have planned in their head.

Do pharmacists make mistakes? Sure. This is no shocking fact. Do doctors make mistakes? Does... oh I don't know... the president of our country make mistakes? Yes and obviously yes.

The stories told in this interview are tragic and unfortunate. They are definetly worthy of a heartfelt apology and even a news broadcast. Are pharmacists villians? Harldy. Compare the few tragedies with the millions/billions of smooth and even beneficial prescription transactions and there isn't much of a story.

Posted by: Ann | Mar 29, 2007 4:20:00 PM

The Walgreens in my small town made a much smaller error switching the labels on two prescriptions. Because they provided a lame apology, we pursued it with our state pharmacy board who finally took action. I sincerely believe the percentage of errors is not as small as Walgreen's wants you to believe. How would they know, they don't keep track.

Posted by: Saul | Mar 29, 2007 4:31:22 PM

i would like to say that i have had to take many prescriptions to the pharmacy for a child or family member, and i have to say the error also lies with the dr writing the prescription also. Dr's themselves have such terrible handwriting, it seems these pharmacist also have to read what they have written. i know the dr's have told me what the precrition is and we as consumers need to also pay attention to what the dr's are telling us and verify the drug before we leave just in case. we are all human, and need to leave alittle more room for error. this couple got 21 million dollars, no amount of money can say i am SORRY, however that is how corporate america says I'M SORRY.

Posted by: sv | Mar 29, 2007 5:29:21 PM

I don't think there is ANY excuse for pharmacy error. I recently stopped going to Rite Aid because they gave me another person's prescription! Luckily I noticed it right away, but the scary part was that the persons name was not even remotely close to mine.
I do agree with Toby to a point. At the Walgreens that I deal with now, the pharmacy techs cannot answer alot of the questions that I ask, and quiet honestly they DO seemlike they could benefit from more intense training. I'm not saying this applies to all pharmary employees, but as in all customer service fields, there are many poorly trained people out there.

Posted by: Kathy | Mar 29, 2007 6:17:46 PM

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