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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 (279)

User Comments

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

As a pharmacist for several years with experience in both retail and hospital pharmacies, I can certainly identify with the commentary provided earlier by Kristen. To everyone who has experienced a medication misadventure due to pharmacy errors, I sincerely apologize. Most pharmacists work diligently to prevent errors, and are absolutely devastated if an error occurs during their service. To chalk it up to "human error" is just not a valid excuse--I agree that there is no plausible "excuse" when a loved one is caused needless harm. The point that is missing in this blog is the fact that most of these errors occur because the system is broken. To expect a pharmacist to work 12-14 hour shifts without lunch or bathroom breaks and fulfill a minimum quota of prescriptions while answering 7 phone lines and a drive-thru window with insufficient staffing AND be 100% error-free is unreasonable and certainly unsafe---this is why I left retail pharmacy. It is my sincere belief that the drug store chain, not the individual pharmacist forced to work in this environment, should be held accountable for criminal and civil repercussions when errors are made that harm patients---only then might the system repair itself.

Posted by: christy | Mar 29, 2007 6:18:35 PM

Everyone always blames the pharmacy, when the doctors make most of the errors. Sure they make mistakes, but so does every business in America. Walgreens is a company with a rich tradition. They are one of the most ethical companies in the U.S. As Americans we only look at what companies or individuals do wrong, not how many times a pharmacist has SAVED A LIFE DUE TO DOCTOR ERROR. Next time you are in a pharmacy and you are sick and angry don't take it out on the technician or the pharmacist when they tell you it will take 15 minutes, be patient.

Posted by: Chuck | Mar 29, 2007 7:39:55 PM

Before completely blaming the Pharmacists, some of these posters should sign affidavits that they have never, ever made an important mistake. Nope, not one.

Pharmacists are also human (most of them, anyway), and will make errors. There's no getting around it. "Fire the pharmacist!" cries will only guarantee that no one trains to be pharmacists any more, and the next thing you know, Billy the checkout bagger is filling your prescription (no offense, Billy). Or, prices go even higher as pharmacies pay higher and higher salaries, trying to attract Pharmacists back to the industry.

Some pharmacies have double-check protocols in place where a 2nd trained employee must verify the prescription was filled correctly. This should be federally mandated for all pharmacies. It must include as a minimum: 1) frequent mandated breaks in the work day, 2) a second, properly trained employee verifies that a) the prescription has been filled as ordered, and b) the prescription is appropriate for the patient. This must be done as an *entirely* independent step to be effective.

Finally, we as patients or parents have to check the results, also. The dangers are too great not to.

Posted by: Dave | Mar 29, 2007 7:50:16 PM

I have been a pharmacist for 27 years and this is a problem that has been caused by society in general. Everyone is in a hurry. If pharmacists were allowed to take their time filling every rx this wouldnt happen. the comment made about technicians filling prescriptions is wrong. technicians don't fill prescriptions, they input the rx and pull the meds for the rx and then the pharmacist checks everything to make sure it is correct before the patient gets the medication, so if a mistake is made, the pharmacist catches it and the rx is fixed to make it correct. if the pharmacist misses a mistake the technician who inputted the rx then their is a misfill. I catch many mistakes every day that the doctors who write the rx's make and verify anything that doesnt seem right or cant read with the doctor's office before filling the rx. I now work at a hospital outpatient pharmacy and can take the time needed to do everything accurately. if a customer complains to me about taking too long, i ask them one question: do you want the correct medication, dose, directions, and counselling ?
if they answer yes, i tell them to sit down and wait till i have it ready. if they say no then i hand them back the prescription and tell them to go elsewhere.

Posted by: mark | Mar 29, 2007 8:30:37 PM

I'm a current pharmacy student. I just want to echo the recent graduate's comments. Retail pharmacy is a very high stress job situation. The number of medications that exist, from the very popular to the very obscure is almost limitless. Doctors don't always know how medications come, how to dose them, or their drug or disease state interactions. We do the best that we humanly can. In between answering 3 phone lines, taking care of the patients at prescription drop off and at pick up, dealing with the drive through, calling insurance companies, verifying hundreds of prescriptions a day, and counseling patients on prescriptions and many OTC questions, pharmacists still manage to catch thousands of errors daily. Studies have shown that pharmacists' involvement in medication management has actually saved hundreds of millions of dollars by preventing medication related errors. While sadly, the occasional error does occur, I would challenge anyone to name a profession that never had a flaw. I do not know any of my peers that would ever intentionally harm a patient. We got into this profession to help people, not to hurt them. To state that we are in any way criminals for a mistake is absurd!

Unfortunately, there is a huge shortage of pharmacists. One person is doing the job of 2 or 3 and you're not going to be perfect all the time in that environment. While that is of little consolation to the families of those who may have been hurt, there are reasons malpractice insurance exists for all medical professionals.

The only thing this story can do is stir up controversy. Pharmacy has been one of America's most trusted professions for decades. We earned that ranking for a reason, but I doubt I'll ever see a news story showing that side of the story.

Posted by: rpd | Mar 29, 2007 10:14:54 PM

Where I work the Pharmacists must work 7 days straight and 12 hours a day 9am-9pm. Who in their right mind can expect 100% mistake free perscriptions? Especially when filling almost 300 a day? Come people use your head!

Posted by: Denise | Mar 29, 2007 10:15:53 PM

I'm an aspiring pharmacy student that works at Walgreens on the side. Just so you know, there is an error-checking system in place along each part of the workflow thru the pharmacy.

I have to say I am appalled that Walgreens, nor the pharmacist, ever apologized to the family. I must work at a really good pharmacy because if we do make a mistake, we immediately apologize and try our best to satisfy the patient's needs as quickly as possible.

However, these comments about making pharmacists "criminally" liable are ridiculous! If you've never worked a day behind the counter, then you have no right to presume to know how to do the job correctly. It's very stressful and mistakes do happen. But I've seen pharmacists go out of their way to fix a mistake a MD made or even give free Albuterol solution for an asthma patient because they had no insurance or a doctor is unreachable to authorize a refill.

Posted by: Cathy | Mar 29, 2007 10:54:40 PM

Why would anyone want a law that holds pharmacists CRIMINALLY liable for a mistake? That is absurd. It is one thing if the pharmacist is wreckless (drunk on the job, etc) - but an honest mistake shouldn't result in a pharmacist being deprived of their liberty. If you start throwing people in jail for mistakes, you will soon find that no pharmacist is willing to work. Then you won't have access to your medications. It will not be unlike the OB-GYN shortage in California. Is this really reasonable? Do we live in a society that punishes people for honest mistakes?

Posted by: Burt | Mar 29, 2007 10:55:16 PM

I will say again.... Everyone makes mistakes. Being a pharmacist for a large chain store is a very stressful job. To say a pharmacist or other healthcare professional is ignorant, IS ignorant... it's not about a pharmacist's education and knowledge about the actual drugs, but about the MANY other things going on requiring the pharmacist to multi-task during a normal work day. A pharmacist would love to share their vast knowledge about medications, disease states, interactions, and/or side effects, but they very rarely have the opportunity to voice any of this information due to handling insurance claims and unhappy customers, calling physicians, and checking filled prescriptions. And if they do use this knowledge and discover a mistake by a doctor, or counsel a patient on OTC meds, it is unrecognized.
Pharmacists deserve more credit for all that they do. It is never a good thing to make a mistake, but don't demean and disrespect a profession that is very important in the healthcare field. And yes, every pharmacist should know that it is their duty to apologize for any mistakes made, regardless of how the mistake came about. No one is perfect, in any profession, in any field, in any type of situation.

Posted by: Kelly C. | Mar 29, 2007 11:22:28 PM

Would you rush your pharmacist if you know a mistake can kill you?

I think it's a good thing ABC is airing this story. It's unfortunate but many mistakes are not reported. That's a fact. Most pharmacies are understaffed and most patients don't understand the importance of our work. I hope the story explains why mistakes are made but I think the story also needs to be fair. It needs to explain that pharmacists catch many more mistakes than make a mistake.

I think most of us try our best to prevent mistakes but there're many ignorant people in this world. I have people who got angry at me because I want to verify their date of birth, just to make sure I am giving the right medication to the right person. Some physicians have the same attitude. Have you tried reading your physician's handwriting?

Posted by: HD | Mar 29, 2007 11:31:11 PM

As a pharmacy technician student who will be taking pre-pharmacy in the fall, I feel I need to respond to some of these comments. Kristin was completely correct in saying that a pharmacy, even a small one, is extremely busy. I have been finding that out first hand as I have been doing my first rotation of clinical experience for my program. There are times when our pharmacist is on the phone, we have like 10 people waiting on prescriptions, and the counter is full of prescriptions waiting on the pharmacist to check them. I know first hand how easy it is to misread the prescriptions that come in. Doctors are in a hurry and scrawl out their orders and its up to the techs to figure them out. Its easy to misread the label and grab the wrong drug. But pharmacists are not all "Idiots". There are always a few bad apples, like this particular one who refuses to apologize for the damage he unwittingly did. But to toss out even more regulations and rules is just going to make pharmacists and pharmacy techs start to vanish like doctors are doing. Mistakes happen, pharmacists and pharmacy techs are human. Errors should be expected. Everyone should always check their own medication as soon as they come home from the pharmacy. If its something you take on a regular basis, you should know if something isnt right. It is ok to question your pharmacist and the techs too. They are trained to answer your questions. My sympathy goes out to the family of the little girl who was sickened.

Posted by: Tonya | Mar 29, 2007 11:43:54 PM

I have to defend the pharmacists on this.They deal with thousands of customers a week.Anytime I am at a pharmacy, all I see are short tempered customers demanding immediate service.The workers are always on the phone trying to do the customers legwork of calling their insurance providers.I used to work in retail.I can understand that when dealing with millions of customers a year, mistakes can be made.My only question is,does anyone ever blame their Dr.'s for possibly writing wrong or illegible prescriptions?I am a Walgreen's customer myself,and it's almost overwhelming how many questions they ask to verify my prescriptions.From being an ex-retail employee, I would just like to give some positive credit where it is due.

Posted by: Aaron | Mar 29, 2007 11:59:25 PM

Pharmacists must assume full responsibility of any mistakes made under their watch. And many unfortunate things have resulted from errors, but speaking as a certified technician for 5 years and a now a student earning a Pharm D, I believe patients should take a more active role in their healthcare.
Many of our customers refer to their meds as "the white one" or "my sugar pill." They pick up their RX, in a rush, while talking on the cell phone, and refuse any counseling. And the drive thru! My pharmacy doesn't have one, but those things seem to complicate every problem as well. How can a pharmacist adequately and confidentially counsel a patient through a scratchy speaker phone??? Please come inside, health care is not a fast-food service!
Patients need to be more responsible for their healthcare in general. Slow down. Know what you are taking and why. Know the color and shape of every pill, check the name on the bottle, and discuss the directions and side effects with the doctor as well as the pharmacist. Don't be afraid to ask any questions, and call us when you get home if there are any problems. If something seems wrong, like taking 5 tablespoons of an anti-biotic then it probably is.
Bottom line, pharmacists should be held responsible all scripts that they verify and dispense, but they are human and obviously not perfect. By having patients double check their meds, we may not be able to reduce pharmacy error, but we can definitely prevent some of the deadly consequences.

Posted by: Jessica | Mar 30, 2007 12:16:07 AM

A month ago Walgreens made a terrible medication error and gave me a time release capsule form of a Schedule II medicine that I take in normal tablet form. I have worked in the medical field and always check my medication. When I saw what they had given me instead of the correct form of the drug I was stunned. I had had just assumed that it was a cheaper generic form and taken my normal number an taken in this time release form I believe that I would have been is very serious trouble. I called immediately to correct the situation and told my doctor. He advised me to change pharmacies. I probably should have reported it to the state board of Pharmacy because doubt Walgreens did.


Jim
NM

Posted by: Jim P | Mar 30, 2007 1:20:34 AM

Just reporting the mistakes is NOT addressing the REAL problem. The pharmacist are working too many hours with too few breaks. Anyone under those circumstances are most likely going to make mistakes. So how will reporting it fix the mistakes? It won't! The mistakes are NOT happening because the pharmacist are not paying enough attention! They are happening because of no regulations on the working conditions of the pharmacist, and because business people do not want to pay for additional pharmacist to be on duty to help. Instead, they sacrifice the publics safety just to save them some money! That is where the REAL problem is! These BUSINESSES need to be required by law and regulations to have a sufficient amount of pharmacist working at any given time. If the BUSINESS violates that regulation, they should be criminally charged, PLUS fined such a HUGE amount, that it would deter ANY BUSINESS from trying to cut corners on cost and endangering the publics safety! I'm not a pharmacist, but I've seen the UNSAFE CONDITIONS they have to work under! I hope 20/20 points the finger to the REAL culprit: the BUSINESSES and their GREED to SAVE MONEY with a LACK of CONSIDERATION for SAFETY!

Posted by: C.Mundy | Mar 30, 2007 3:16:10 AM

My heart goes out to the Gehrke family. What a shame that a normal healthy beautiful girl has to suffer for a mistake a careless pharmacist made. There should be no excuse for this. I think the pharmacist license should be revoked. I also think a trust fund should be set up for Alexandra so she is taken care of for the rest of her life. I will keep Alexandra in our prayers.

Posted by: Betty | Mar 30, 2007 3:23:22 AM


The investigation fails to point ou how many errors are CAUGHT by pharmacies every year. It is my experience that there are many more errors in physicians PRESCRIBING rather than pharmacists DISPENSING prescriptions.

Posted by: john | Mar 30, 2007 7:37:25 AM

Last year, I had a prescription of insulin filled at our local Wal-Mart Pharmacy in Southport, NC. As we had been filling the prescription there for an extended period, I did not look closely at the bottle before allowing my daughter to fill her insulin pump. She filled her pump with the insulin and it was the incorrect prescription all together, she ended up in the emergency room and it took almost a week to regain control of her blood sugars and insulin doses. Wal-Mart implied that I SHOULD HAVE noticed the problem before leaving the store. I reported the problem to the NC Pharmacy Board and Wal-Mart received nothing more than a warning. This is very discouraging and I am hopeful that this never happens again, specifically to someone older who does not have a live-in caregiver, as this type of mistake can result in death easily to someone with diabetes.

Posted by: Abby Lassiter | Mar 30, 2007 7:42:25 AM

I've just recently had the same issue with Walgreens typing the wrong dosage on the label for my 4 year old son. It was double the strength he should have gotten. I also had the same issue with Eckerds when my son was an infant. Eckerds had typed 1.5 teaspoons instead of 1.5 milliters. Walgreens did apologize, but Eckerds was defensive to admit their mistake saying it was the Dr's handwriting that made it hard to decipher. My gosh they have a college degree and should know an infant can't take a teaspoon full of medicine in the first place. Plus why didn't they call the Dr to clarify what was written? I always have the Dr explain exactly what the prescription dosage and the medicine will look like ever since that first time with Eckerds issue. I see it the same as medical malpractice..so why are they able to get away with it if it affects a persons life but Dr's or nurses would have a malpractice law suit on them?

Posted by: M.Crosby | Mar 30, 2007 7:58:47 AM

I am a nationally certified pharmacy techician who has worked in that position for over 20 years. I watched Brian Ross on Good Morning America this morning and became very angry at a statement that he made at the close of this segment, when he stated that people who sign the prescription log are waiving their rights to counselling. This is absolutely untrue!! I have never worked in a chain pharmacy, have always worked for independents. We have a very strict system of checks and rechecks for our prescriptions, and when we have our customers sign the Rx log, we constantly ask them if they wish to speak to the pharmacist about their prescriptions, or if they have any questions at all. Even if there is a slight adjustment in the dosage of their meds from the doctor, we always inform them with a note that we attach to their prescription receipt. We also have a column on our signature log that they check for couselling or non counselling. As a well respected and trusted neighborhood pharmacy, we take care and pride that we give our customers the right prescriptions and the right instructions. Our pharmacists are right on top of everything. I guess there will always be professions to attack, for news reporters' careers, and I suppose that this week the pharmacy technician is it. Just remember, there is a difference between a pharmacy clerk, a state registered pharmacy techician and a nationally certified one. In order to be certified nationally, one has to be schooled in the profession and pass a national exam, as well as keeping up with continuing education credits yearly.

Posted by: Sharon | Mar 30, 2007 8:01:05 AM

I totally agree with Jessica. I may not be a tech but I have worked as one for 4 years and the first year I was in High School. Also Jessica is right on about the drive thru, it is very hard to assist people through it. And people do think its like McDonalds, i'm sorry but thats not what it is there for, it is for people who cant get out of their car, parents with kids, or just older people who have trouble walking. Its not for people who are just to lazy to get out of their cars, and the funny part is that they are the ones who are mad because we are not that fast. Another main issue is that people should always be aware of what they are taking and honestly we praise people who call and ask questions about why their pills look differnt. Also I may not work for Walgreens but I do work for a chain pharmacy and we also have people sign in order to pick up their scripts, I alway encourage people to ask questions. They might decline to be counseled but they always have the right to ask questions. I cant speak for walgreens and i dont know how they work but people have every right to ask questions and no signature can denied you to speak to a pharmacist at any time. I also think that 20/20 should invistigation on how people treat pharmacy techs and pharmacist. People are very disrespectful to us and 75% of it is'nt our faults.

Posted by: Anna | Mar 30, 2007 8:09:55 AM

I am a Certified Pharmacy Technician and I have worked at Target Pharmacy for almost 5 years. Target as a Corporation puts the guest first and expects our pharmacists to counsel our patients. In fact there have been guests that pick up over-the-counter medicine that I personally have asked the pharmacist to counsel, considering their medication profile, to make sure there is no conflict with their medication. Target also has a corporate-wide triple check system and have caught errors made by Doctors, Techs and computer generated errors on computer prescriptions. Also, Target has the ClearRx prescription bottles that includes a "message-in-the-bottle that slips in a pocket on the bottle or stays with the medicine or with the package. It is a "reader's digest" verson of the patient information sheet. It includes a description of the medicine that is supposed to be in the bottle. We even have 6 color choices as part of our packaging of a prescription that correspond to individual family members so they know their individual color and are double sure it is their medicine bottle-sometimes family members are on the same medication but different dosages, this allows individual family members to "see" their color as a double check-(color and name). While there are errors that do occur, I am proud to say that I trust my hometown Target Pharmacy and KNOW that my pharmacist makes and is allowed the time to talk with our guests whether the guest wants it or not. Our signature log is ONLY for proof of pickup. There is a prompt on the register for us to remind the guest that the pharmacist is ALWAYS available for counseling. Even when they get home. I love our pharmacy and I love the way Target allows us to help our guests.

Posted by: C. Perry | Mar 30, 2007 8:16:40 AM

This is so bazaar...I have three incidents recently with Wal Mart. My doctor had called in a medicine that I had never taken before. I went by to pick up my medication, they could not fill the complete precription which was fine. I usually check out my precription on the spot but did not that day. Next morning I read the script on the bottle. It had my name, I wasn't sure if it was the right medication, It had the wrong doctor's name on it.
Then I had the flu, my general practioner in town, call me in some medication, my spouse went to pick up and when I open it,, Guess what Wrong Doctor's name.
Both incidents, I call pharmacists and the managers and the pharmacist said he has taken care of the problem and apologize. He told me to just call him if I ever have a problem. Sometimes when they try real hard to fill medication for difficult customer, they still make mistake.
I made no reply. I did not feel that I was being difficult.
I was just thinking of how many people that never check their medication they trust the staff behind the counter. It is so scary..What are we to do??????

Posted by: Marsha | Mar 30, 2007 8:19:17 AM

I am soon to be pharmacist (I graduate in May 2007).

Just to clear up the confusion, pharmacists and pharmacy technicians are not the same. To give you an idea of the training that is involved for a pharmacist:

I have a bachelor's degree in economics and a doctorate degree in pharmacy (4 year graduate program). I have completed 1500 hours of clinical practice experience and I have worked as a technician for over 4 years. I will take the NAPLEX national board exam for pharmacy and Virginia state drug law exam. I will also complete 15 credit hours of continuing education every year. I am also a soon to be certified EMT-B. The pharmacy curriculum is extensive- pharmacology, pharmacokinetics, pharmaceutics, pharmacotherapy, medicinal chemistry, biochemistry, physical assessment, law and ethics.

I think this report could be more balanced by showing how useful pharmacists can be in reducing drug errors. Billions of prescriptions are dispensed every year. Without pharmacists, the error rate would be much higher.

Posted by: JC | Mar 30, 2007 8:27:50 AM

ignorance is never a proper excuse. Hurting someone because there are 400 prescriptions to fill out is Still not an excuse. If people have to wait and be inconvienanced for it to be Correct than that is the proper price to pay and nothing more.

Posted by: Rhonda | Mar 30, 2007 8:29:41 AM

Everytime I goes to my drug store to get my medicines I got to sign my name down on a piece of paper. I don't know why. If we don't sign your name on the paper we can't get our medicines.

Posted by: Anita Marable | Mar 30, 2007 8:32:53 AM

As a current pharmacy major/student intern, yes it is true that many technicians are high school students or people who only have a high school diploma. But really all they are supposed to do is count the pills for the pharmacist, run the cash register, and enter data, which is required to be double checked by the pharmacist. Like the guy said, Walgreens fills hundreds of millions of prescriptions every year so of course there will be some errors here and there, but that number is very small. And as far as signing away your rights, if a technician checks you out they are supposed to ask if you have questions for the pharmacist before they have you sign a log, and if you say no then youre saying you dont want counseling. I don't think its that misleading, this is just poor reporting on a slow news week.

Posted by: Matt | Mar 30, 2007 8:48:58 AM

As a Pharmacist for 26 years, I can truly say that I have made mistakes and I can truly say I have been upset at each and every one of them. I do hope that the public watching this news report will realize that Pharmacists do care and never want to make a mistake, but we are human. I know though that in my Pharmacy we do our best to not ever have an error and you want the error rate to be zero. We work so hard to do the right thing for each and every patient, but we are bombarded with so many other issues that it is very hard to practice what we are taught in school and be the best for each and every situation. I apologize to each family that has been involved with an error that was made on our behalf, but I can promise you that we have kept thousands more from happening due to our diligence and work ethic. This story will be one sided for sure, but each day our profession tries and succeeds at doing so many wonderful and helpful things that we should have airtime on his show talking about that. The logbook that is signed in our store is one that we are required to keep for insurance purposes and it is checked by auditors. It is not to say that the patients have waived their right to get counciling. I know fairness in journalism doesn't sell and I know that both sides won't be seen, but I have to sleep at night and I know that I have tried my hardest each day I work to do what is right for everyone concerned. I know that I'm not alone because the Pharmacists I know all feel the same.

Posted by: Drew Miller | Mar 30, 2007 8:54:09 AM

First of all being a technician is not a high schoolers job. It is walgreens fault for hiring someone with no expierence or certification in pharmacy. I am a certified and registered pharmacy technician and have been in pharmacy for 10 years!! It is not a field you want to have person after person coming in and out of. In the state of Texas you must be certified, by taking a 4 hour pharmacy exam, and registered with the state. In the pharmacy where I have been employed by for 8 years (not walgreens), when you sign the receipt when you pick up the prescription, you are signing that you picked it up. Anytime the customer, either does not want counseling or walks off without counseling, we put a RC for "refused counseling" just to note for our records that it was their choice not to receive counseling, but just because they sign the receipt does not mean they agree that they have had counseling. In Texas, we only have to give, "offer", counseling on their original rx and once a year thereafter for that same medication. It would be best for our PROFESSION, yes it is a profession and not a high school job, if you were to state the facts more clearly and if you would also state the facts about the location and how patients are so demanding and want their prescription NOW and do not want to wait 20-30 minutes for us to to all of the checks we need to do to make sure we give them the correct directions and correct strenght. You may also want to state the fact that it does not take 5 seconds to fill a prescription and that maybe the patients should be more patient. When you put a story on line and on tv you need to make sure you cover all of your areas and you are confident of your story from all ends, because stories like these, put a bad wrap on all of us and I do my job very good and very careful, with or without breaks and lunches!!!!!! And I am NOT a high school student, this is my choice of a lifetime job!!!!!

Posted by: Brandy | Mar 30, 2007 9:01:16 AM

I had a total abdominal hysterectomy a couple of years ago. While I was in the hospital, I did so well with pain management that I was released a day early to go home. I had my prescriptions filled at Walgreesn on my way home, one for a prescription strength Ibuprophen and one for a narcotic pain medicine, meant to work together to keep the pain minimized. The bottles were marked correctly, but inside the bottles the pills were incorrect. I had taken what I thought were the prescribed doses the day I came home from the hospital but my pain was getting worse. It turns out that I was given two bottles of prescription strengh Ibuprophen but didn't realize it until the next morning when I got up in such severe pain that I was doubled over and crying. . I called Walgreens headquarters to report the incident as well as the state department of inspections and appeals. To my knowledge, there was no disciplinary action against the pharmacist, the pharmacy tech or Walgreens. Since my incident, I have talked to many people who have had their prescriptions filled at Walgreens (not even at the same store I used) and have heard story after story about prescriptions being filled wrong. This is insane that in today's world, these types of mistakes are happening!

Posted by: Jeannie | Mar 30, 2007 9:03:39 AM

I am a certified pharmacy technician in a major retail chain.

Regarding the signing of signature logs: the patients are NOT signing away any rights. They are simply acknowledging whether or not they have any questions for the pharmacist about the medication they're picking up. This does not prevent them from changing their minds and asking a question later.

Re pharmacy personnel not being able to answer questions. If the question relates to the drugs, their effects, their interactions, etc., then only the pharmacist or a supervised pharmacy student is allowed to answer the question. It's not because the other personnel are ignorant or insufficiently trained. It's because they are not pharmacists!

Any error is, of course, one too many. But yes, they happen occasionally...and sincere apologies and efforts to correct and compensate should always be immediate. However, there is no one in any profession who can say he or she has never made a mistake. Because of the potentially tragic consequences, it is indeed imperative that safeguards be in place. There are already many, but systems are imperfect. And as already pointed out, the pressures of the business model rather than a health model are a major contributing factor. But where do those pressures ultimately come from? The customers! They want more, faster. Customers are often indignant if they're told they have to wait more than 2 minutes for a prescription. How often we hear "it's just a box, all you have to do is put a label on it!"

So yes, we can always strive to be better. However, I challenge all of you to also strive to be better consumers. Give your pharmacist plenty of time to fill non-urgent prescriptions. Don't get irritated when we ask you questions. We really do want to serve you well and keep you safe and healthy!

Posted by: Nancy | Mar 30, 2007 9:09:48 AM

I am a Pharmacy Technician, we are required to get signatures when we fill prescriptions using insurance. Also there is a state law in Arkansas that we see a drivers license and keep a log when we sell any ingredients that are used in making meth...

Posted by: Laura Robertson | Mar 30, 2007 9:27:04 AM

As a CPhT in FL I have seen many mistakes made at the CVS locations where I worked. The problem is RpH's that are from India and other countries brought over on Visas from these pharmacies. The requirements are different in these countries, and the English is passable at best for many of these pharmacists.I plan to go to Pharmacy school one day but it might be cheaper and quicker to get my degree from another country!

Posted by: Alissa | Mar 30, 2007 10:03:51 AM

Has any one looked at mail order? You do not have the opportunity to ask the questions as to if your Rx is wrong and I believe the error rates are even higher.

Posted by: samuel | Mar 30, 2007 10:09:17 AM

Businesses are out to make a profit but when it risks the safety and welfare of human life, we need to ask what do we do to correct it. The teenager's mistake in Florida who caused a young woman of three children her life should be addressed. The family lives with the pain and loss of their loved one. The teenager lives with the fact he/she made a mistake that ultimately killed someone what is the psychological consequences there? Yes mistakes are made in any business but when profit is the first principal and ruling factor that operations are governed by, then the people who govern them should be the ones held accountable for their employee's mistakes. If the president of Walgreen's was accountable for what the technician's and pharmacists did in every one of his/her/their stores; there wouldn't be a problem and they would make sure of that especially if their neck was on the line.

Posted by: cathy | Mar 30, 2007 10:26:14 AM

After viewing the Good morning America show and reading this on-line, I have a great solution to this problem. Let's just shut down and close all the pharmacies across the country. Maybe we all can purchase "safer" meds from outside the country.

Posted by: Paul | Mar 30, 2007 10:28:29 AM

I system is flawed seriously. You are blindly trusting another human who fills countless prescriptions every day and this goes on for years. I cannot blame him for a mistake but that one mistake can be so so serious . I have seen an altogether different system in India. All the drugs are delivered in their original (manufacturer) packing so the name (and composition) is clearly marked on the drug (very similar to over-the-counter drugs here). There is nothing over the counter in India and everything has to come from a pharmacist. This can avoid such situations where patient can very well read the name and the composition of the drug he/she received. I know there are other serious flaws in this system but if we focus on core problem, this might well be the answer.

Posted by: Share point | Mar 30, 2007 10:36:46 AM

Being a pharmacy educator focusing on medication safety and adverse drug reactions, I can say that I have seen numerous of hospital admissions attributed to adverse drug reactions. When analyzing these events, nearly half of these events have some form of "preventability" and generally they fall into the category of not dispensing errors but the errors of omission, that is the failure for someone (pharmacist, physician, and patient and the interactions between these groups) to detect certain factors that most likely lead to the adverse event. These factors include, failure to detect a disease state contraindication to the drug therapy, failure to detect a significant drug interaction and how to manage or avoid, failure to detect a significant drug allergy, failure to prescribe the correct dose for that specific patient (elderly, renal impairment, et al.), failure to monitor therapy for drugs with narrow therapeutic indices, and patient knowledge deficits. Many of these can be avoided with a few minutes of counseling with prescriber and/or the patient. Pharmacy computer systems are not standardized and are only as good as what is entered into these systems, not only by the software programmers, but truly by the users, i.e, pharmacists by taking adequate medication histories, and doing what I believe is the crux of their positions, the prospective drug review, where new prescriptions must be screened with other concurrent medications and disease states. If a proper history is not at hand it is the responsibility of the pharmacist to ascertain this. All too often, the person handling the initial interaction is a pharmacy technician and not a registered pharmacist, and unfortunately this initial interaction may be a missed opportunity for the pharmacist to glean this information. Factors such as "business and distractions" are a reality, as I too, also work as a pharmacist, but it does not recuse any pharmacist from performing what is expected by their state boards, their profession and the public. The key trait that I expressed to our PharmD students is that a pharmacist must a detail-orient professional. Equally, I am hoping that this program focuses on the many interventions pharmacists do make that detect many prescribing errors.

Posted by: Patrick | Mar 30, 2007 10:37:42 AM

I was appalled to learn this morning that the piece of paper we sign at the pharmacy is NOT merely an acknowledgement of having received our medication, but rather signing away our rights of remediation due to an error on the pharmacy’s part. This is, as far as I am concerned, a total deception!

I have made a habit, when I am AWARE that there are items in a document that I am told I MUST sign that I do not agree to or with, to actually cross out the items I do not agree to, or add additional comments of my own, prior to signing it. I can assure you that I will NOW make this a practice when signing my prescription receipt documents!

Posted by: Aimee | Mar 30, 2007 10:48:06 AM

This investigation discusses patients signing away their right to counseling. National pharmacy associations and state boards of pharmacy are making efforts to have more counseling done by pharmacists. This is a huge shift in practice since 50 years ago it was illegal for pharmacists to discuss a patient’s medication with them. Laws are in place in many states that require pharmacists to counsel or offer counseling to patients.

The reason why pharmacists do not actually counsel on all prescriptions is because there is no reimbursement for a pharmacist's counseling services. Along with this, cuts in prescription reimbursement by both government and private insurance companies necessitate that pharmacists increase the volume of prescriptions