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ABC Story Leads to Deluge of Pharmacy Error Reports
April 02, 2007 11:53 AM
Hundreds of readers and viewers have reported pharmacy errors in the wake of an ABC News investigative report on what some fear is an unreported epidemic of such errors at large chain drugstores.
"I had a similar experience at Walgreens in 2003," wrote Pam Koster from Littleton, Colo., in a comment on The Blotter Web site.
At the time, Pam explained, her four-year-old son Michael had just been diagnosed with leukemia. After he had spent five days in the hospital, Pam brought Michael home and filled two prescriptions he needed for his treatment.
THE BLOTTER RECOMMENDS
That night, as Pam prepared to give Michael his first doses of the medications, she read the directions from the bottles and thought something was odd, she told ABC News.
"I said, 'This doesn't seem right,'" Pam said she recalled. Checking with the local children's hospital, she says her fear was confirmed: the pharmacy had mixed up the instructions on Michael's medications, advising Pam to give her son a much larger dosage of a powerful drug, Dexamethasone, than the hospital had directed and to give him much less of a second drug, Methotrexate, which was key to curing his leukemia.
Click Here for Full Blotter Coverage.
"I went to Walgreens the next day, first thing in the morning," Pam told ABC News. "The pharmacist who filled the prescription was there. I asked to talk to him specifically. I showed him the labels and said, 'This isn't right. I want you to pull what the hospital called in and show me what you did.'"
According to Pam, the pharmacist said he did not have the paperwork handy but would look into the matter. At first she resisted, Pam said, but eventually gave in after being promised the store would call her later that day with more information.
The pharmacist's supervisor called her that afternoon, Pam told ABC News. Pam says she admitted the error and vowed to bring it up at the store's next staff meeting.
"We all make mistakes in our jobs," says Pam, whose disturbing story was one of dozens posted to ABCNews.com in response to the "20/20" investigation into pharmacy errors. "But there's got to be some sort of way these things can be reported. I'd like to be able to go to a [W]eb site and [look up] this Walgreens," Pam says, or even a specific pharmacist there, "and see what their track record is in terms of errors."
Walgreens has declined to address any specific incident of alleged pharmacy error. In a statement last week in response to the ABC News "20/20" investigation, 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."
Improving wages for pharmacy technicians and increasing their training and credentialing requirements would also cut down on errors, some readers said. Lori L., who interned at a chain pharmacy in Nevada, urged Americans to make their voices heard if they want to help raise awareness.
"Unless people speak out, nothing will change and errors will continue to be made by uneducated, undedicated techs who should not be in the profession," Lori wrote in her comment on The Blotter.
She told ABC News she became convinced for the need to fix the system after catching multiple errors made by pharmacy techs at a chain store where she helped out as an intern. "I was still theoretically a student," Lori told ABC News, "[and] I caught errors that supposedly experienced techs were making."
Of pharmacy technicians, Mary Ann Wagner, senior vice president of the National Association of Drug Store Chains, said, "We depend on them very heavily in our industry," saying there is no problem relying on technicians if they are adequately trained.
April 2, 2007 in Pharmacy Investigation | Permalink | User Comments (143)
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Here's the thing. Many of these mistakes have no correlation to training - it's attention to detail and having a process to double check prescriptions prior to them going to the customer. I recently had a very similar issue with Walgreen's and when I started asking questions to try and figure out why my son was having an allergic reaction - I got the run around and was treated with a complete lack of respect because I didn't understand the terminology being used. I got my pediatrician involved and the pharmacy staff changed their tune. 2 weeks later I gave them another chance and tried to fill 4 prescriptions give to me from the hospital for an allergic reaction I had to Omnicef - the tech got irrated with me when I wanted to check the what he gave me - even after I asked for no generics. I got 1 generic and they didn't even tell me that they we out of stock on one prescrip - the EpiPen - which can be life saving for those with sever allergic reactions. I had to ask for the prescription back - which the tech was irritated because "they were busy". Very disappointing. Needless to say I'm changing pharmacies.
Posted by: Kelly | Apr 3, 2007 9:02:38 AM
I am a 27 yr old pharm tech for a major chain and have been for the past 7 yrs and I am insulted by this report. I take my job very serious, I think it's the public that has a problem. They need to take some responsibility for their own lives. I can't even keep count of how many times a day one of us gets yelled at because we tell someone the wait is 15 min. we always hear "really, you just have to put a pill in the bottle and slap a label on it..." I think you need to put a hidden camera behind a pharmacy counter and see how we get treated. Oh, and if it's been 1 second past that 15 mins people will stand at the counter and stear at the pharmacisit and ask what is taking so long. Now you tell me that wouldn't make you a little uneasy while you're DOUBLE checking a script. You people have no idea what we go through on a daily basis and how stressful this job really is, oh and how little we get paid for it. On a side note when there is a problem reading, or a dosing question on a script and have to call a doctor do you even know how long it takes to get an answer back if we even do...and again people get mad they have to wait. So i guess my point is maybe if the public gave us a little more respect a chance and some time to our jobs and stop treating a pharmacy like a fast food place perhaps these "mistakes" wouldn't happen. FYI we are only human, and I doubt anybody out there can say they have 100% accuracy at their job people have to remember that and that gets lost in all this hipe.I have so much more I could say but what would it really matter you don't care about the other side of the story that is plain to see.
Posted by: Sarah | Apr 3, 2007 9:41:00 AM
I work at Walgreens as a pharmacy technician and I see how our pharmacists and tech go out of their way everyday to help our patients. I see our pharmacists work very hard to care for the people who come in to fill thier rx's, they do pay attention and try their best with everyhting they do. I can't believe how your program made it seem like Walgreen's as a company and each of thier pharmacists just don't care, becuase they do. There is a thing as human error and I'm pretty sure that doctors and nurses have made mistakes too...and sure their mistakes turned out tragic for the patient. It's sad, but it happens and for your prgram to make it seem like Walgreens doesn't care at all is wrong. I suggest you talk to one of the CEO's and find out exactly how much money Walgreens is spending everyday on bettering their technology so mistakes happen less often. We do have the best technology out there and it's not so we can look good...it's so we can help our patients better, how about you put that on show?!
Posted by: Jessica | Apr 3, 2007 10:15:10 AM
This is extremely one-sided, which if you read what has already been posted, it is already clearly stated. I am a pharmacist working for one of the chains you heavily targeted in your investigation. I am not represented in your investigation, except by 1 pharmacist that ran outside to talk to a patient, because I have done that before. I do more than the required continuing education for both of the states that I am registered in. I particularly do CE in areas that I think are my "weak" areas, as to strengthen them. I am constantly counseling my patients. Sometimes they get tired of me telling them things that I've told them before, but I want to remind them. The pharmacy I work at does have an error reporting system. It is a learning process. It errors are made, we must come up with an action plan as to how to prevent that error from occurring again. And everyone in the pharmacy knows about the error, not just those that are involved in it. I am constantly educating my technicians, who are eager to learn. I teach them about max doses, new medications, why things interact, etc. No they are not allowed to counsel the patients, but the more they understand the better. I am the person who is solely responsible for what goes out of my pharmacy, but the more eyes that see that prescription and understand the significance the better. There are many steps in the process of filling prescriptions that are required in order to prevent errors. We use barcode technology and automation when we can. I care about my patients. And realize that they are my patients, not my customers. It does frustrate me a great deal though when these patiens huff and puff over a 20 minute wait on a prescription. You will wait 30 minutes easily on a pizza, but 20 minutes on something that can be life-saving, humph. In America we like to shift responsiblity away from ourselves. The cases that you chose to display are very saddening. If I was involved in those cases, I think I would have to step down from my position, but there is a certain responsibility the end-user must take on. I don't know how many times I have someone come to the pharmacy and they don't even know what doctor they saw or the patient's date of birth. I want to be accurate always, but the patients need to help me be so.
Posted by: Michelle | Apr 3, 2007 10:51:52 AM
I worked as a retail pharmacist for many, many years. I left to take a job in a state run managed care program. I felt I could no longer do my job as it should be done. I was constantly dealing with management regarding reducing payroll, customer service, wait time, inventory, and countless paper work. And make sure the 750 prescriptions that were filled daily were done correctly and each new patient was counseled. This was "company policy". However, I was not given the personnel to do my job. If business slowed, we were expected to send people home. The store manager, who was not a pharmacist, had part of his bonus based on our profits and routinely insisted we cut, cut, cut. It was never enough. Our staff was overworked, stressed, and underpaid. I worried about the potential errors and the lack of time I was able to spend counseling. I decided to get out before something terrible happened. I would never go back to retail pharmacy. It is no longer a profession...it is a rat race.
Posted by: JD | Apr 3, 2007 11:24:57 AM
My pet peeve is with doctors who DON'T write legibly. What is the point in seeing a doctor if they are going to put your life on the line with sloppy penmanship?
There should be a LAW that ALL prescriptions MUST BE TYPED, not written.
See Michael Moore's upcoming movie "Sicko's". Due out this year.
Posted by: Jeff | Apr 3, 2007 12:24:01 PM
I used to be a pharmacy tech for Walgreens and then a pharmacist. Yes, I started in high school. They are not a terrible employer by any means but I would like to point something out. They are the ones who came up with the drive-thru window for pharmacies. I wish the person who proposed that idea had to work a week in a pharmacy with a drive thru window. If we, pharmacists, are viewed by the public as nothing more than fast food type of employees, I think we have Walgreens to thank for some of this. I now work for another chain with drive thru windows. They were put in just so they can compete with Walgreens. I hate to think about what they (Walgreens) will come up with next.
I would like to have someone, perhaps the state boards of pharmacy, look at the ratio of prescriptions filled per person (employee) per hour in any given pharmacy. It can be astounding. There should be some standards set for requirements in this area. One of the biggest problems is lack of adequate staffing. If you are going to have a drive thru window, it sure would be nice to have an extra employee behind the counter to take care of it! But that is not the case. It is added on to an already heavy workload.
And here is something that I think is really a hazard, lack of breaks. I can work 10 hour shifts without a break for a meal or anything else. I have to eat "on the fly". Not all the time but many times. That does not improve my concentration ability. I think this is a *very* serious issue. It may make a good reason to shop early in the morning.
Posted by: Lisa | Apr 3, 2007 12:29:06 PM
After the show aired on ABC, I had the good fortune of working the weekend and the FIRST Monday of the month, which is always among the busiest and it now overwhelms and saddens me that this story will ultimately do more harm than good. I happily took calls from many of my patients finally wanting counseling regarding their medication so for that I thank you. However, there were many patients with disease states that cannot afford to be off their medication wondering if they should continue it, if myself or the doctor knew of the interaction and complications, if mistakes had EVER been made and they were not made aware of it.
I had to convince an elderly man with a history of decubitous ulcers to continue his diabetic medications! This is what happens when one reports on a portion of the story. The public depends on health care professionals to be the expert and specifically the pharmacist to be the drug expert, just as they trust journalists to report honestly and ethically, which to my patients, yes they are my patients not customers, to their detriment you have not done so. One problem we face in the health care profession is patients who underuse their medication because of cost, etc now you have added another burden to the patients list and another possible reason they will have hospital admissions or ER visits unnecessarily because they are not properly using their medication due to this scare tactic for the purpose of ......what was it again??
Posted by: PharmD2006 | Apr 3, 2007 12:58:05 PM
As a Pharmacist with 33 years experience, I must take great exception to the selective "reporting" that was done on this program. I have worked as an independent pharmacist for 20 years and for Walgreens for the last 13. I found your "facts" did a great dishonor to all the hard working, and committed Pharmacists and Technicians no matter whom they work for.
I would venture to say I have caught hundreds of lethal or potentially damaging drug overdosages or interactions over the course of my career. I can only speak for the state of Illinois, where I work and reside, but to the best of my knowledge there is no system to report Doctor's errors to the state. However, Walgreens has a very comprehensive and thorough error reporting system, and you folks conveniently ignored that. If my technician does everything right on a label, but accidentally types zero refills instead of one, and if I dont catch it, thats an error and it is reported.
But I can't tell you how many times I ask the patient what is the name of the doctor you saw, and the patient stares at me with a blank look because they never bothered to ask the name of the doctor at the emergency room or urgent care center. i cant tell you how many times people demand to know why I am checking the bottle the tech just handed to me instead of just putting it in a bag so they can go. I can't tell you how many times I have had doctor's write for prescriptions for foreign drugs not available in the U.S. because their patient asked for it! Think about that for a second; a doctor writes a prescription for a drug he knows nothing about because the patient asked for it!!!
Posted by: Michael Gershon | Apr 3, 2007 1:02:54 PM
As a pharmacist, I have the following suggestions to the general public:
1). Choose your pharmacist like you would your physician.
2). Ask them how long he works in a single day, how much help he has, and if he gets a lunch break or other type of break.
3). Ask them how many prescriptions they fill in an hour. Using this as a guide, 20 prescriptions per hour equals one every 3 minutes. Personally, I think one prescription every 5-6 minutes is the bottom line as far as safety is concerned.
4). How do they feel about counseling you on your medications (including OTC products).
5). STICK WITH ONE PHARMACY! Don't chase the stores offering transfer coupons. This way you will get to know your pharmacist and they will get to know you, what your are on, how you take it, and over time they will become attached to you and become your biggest advocate.
Posted by: Greg | Apr 3, 2007 1:12:16 PM
You go to McBurgers. You wait in line, then hand the burger tech your insurance card and your order: a burger with extra pickles, large fries, and a Coke. You go to the waiting area and several minutes pass. You are called back to the drop-off window, where you are told that there might be a delay in your order. Extra pickles are not covered without Prior Authorization: your insurance company needs forms filled out by your doctor depicting the necessity of extra pickles. Also, your insurance doesn't cover Coke, but they cover Pepsi. Your doctor is contacted to ok the change and given the contact information to begin the Prior Authorization process. Your order for fries is entered into the computer and reviewed by the manager. Then your fries are double counted by the tech before the manager checks them again and verifies everything is accurate. You are asked to pay a co-pay of $25; medium fries would have been $5, but neither your doctor nor McDonald's has access to the formulary for your insurance.
Have a nice day.
Posted by: Dave | Apr 3, 2007 2:11:48 PM
As a pharmacy Intern I am also shocked and discusted with 2020 for this one-sided report. I was that 16 year old working for CVS and I was better than both of our 35 year-olds that worked there. I am shocked that as such a well-respected news organization you would make such claims without having any FACTS to back what is merely your OPINION.
The pharmacy techs are underpaid and the entire staff is overworked. Have YOU went an entire 12 hour shift without sitting down to eat, or eating at all for that matter? Have you ever had to refrain from urinating just because you were too busy for the last 4 hours? The answer is allowing our pharmacy staff a little break. Don't expect us to have your prescription ready in 5 minutes if you want it to be right.
Also, why is this one of the only professions where you have a doctorate degree but yet you are worked like a servant with no breaks, no lunches and constantly being questioned and criticized. They outlawed slavery years ago! So how about the consumers doing their part to stop complaining about things that are out of our control and waisting our time. This will allow us to do our job better and more efficiently.
Posted by: Michelle | Apr 3, 2007 2:23:51 PM
I am a clinial pharmacist who works in a teaching institution and also works for CVS on an as needed basis. I feel a bit torn about the report presented by 20/20. Granted it was one-sided but somebody had to bring to light what is going in retail pharmacies today. The pharmacist in retail are over worked without enough help. What other profession exist out there where you are not even able to go to the restroom without everything falling apart.
Additionally the fact that there is no designated lunch period for pharmacist in retail baffles me. Nobody should be expected to work a 12 hour shift and not even have a 1/2 hour break to refuel. When I compare the hospital enviroment to retail I am shocked at the lack of mandatory reporting of medication errors. Medication error reporting should be non-punitive.
District managers should not place pressure on retail pharmacist to fill more scripts at a quicker rate. If a store does not meet a certain script quota help will never be provided in the form of a technicina or cashier to assist that pharmacist. The pharmacist would be expected to ring up toilet paper for patients regardless of what is pending in the back. It is time for change. Govermental agencies need to monitor work loads for pharmacist and medication errors to protect pharmacist and the public from cooperate retail chain owners.
Posted by: RX2U2 | Apr 3, 2007 2:49:09 PM
I cannot believe the unresponsible journalism that went into this story. I am a pharmacist in Canada, and I am disgusted by this piece. Pharmacists already have an uphill battle without ridiculous stories like this being aired.
Get all the facts before reporting a sensational story. I didn't think 20/20 was a tabloid.
Posted by: Sam | Apr 3, 2007 3:32:33 PM
I'm not exactly sorry I missed the 20/20 program slamming the pharmacy profession. I think that most people are so accustomed to instant gratification that they almost have a melt-down because they have to wait a few minutes for their prescriptions. I would love to see patients run into the Doctor's office and demand a thorough check-up and to make it speedy all the while complaining about their co-pays and try to bargain with the physician to give a cheaper rate. These types of people will NEVER be satisfied!
My least favorite people to help is those on state or federal assistance that think they are entitled to everything, like we OWE them something! Most of the time they bring in more prescriptions than anyone else and they expect you to hurry to fill them. In general, they are the most demanding and usually the least thankful for services rendered. What they don't understand is that reimbursement on their prescriptions is so minimal that it is almost not worth filling them. In any other country they would just do without, just like the rest of those that are uninsured.
Overall, I believe that mistakes happen because of distractions. There are too many hoops to jump through just to fill a prescription. Just to mention a few: Is it a valid prescription?, Is it the right dose for the patient's age/weight/etc.?, Will insurance pay for it?, Will the pharmacy be reimbursed properly for the product?, Does it need special authorization from insurance company/state assistance program?, Do we have to special order the product and risk keeping a partial bottle on the shelf until it expires?, Now, will the patient pay for the medication? ETC...
Posted by: Sam | Apr 3, 2007 3:42:50 PM
1)The video was good and informative but laced with such negativity in an attempt to push viewers into unnecessary alert when it comes to mistakes in the pharmacy. but then again, that is what the media does, and what it's good at. Considering pharmacies DO fill anywhere from 100 to 700 scripts a day, mistakes unfortunately CAN happen but does not happen OFTEN. walgreens especially has adopted new measures in limiting mistakes from happening, ie, installing a machine that matches a bottle of drug to the label itself, ensuring the right pills go into the right bottle, for example. That was not in the video.
2) ALSO, it is NOT TRUE that pharmacists are expected to fill 300+ medications on ONE SHIFT. i would say a pharmacist usually fills half of that during his entire shift, and in the case of extremely busy stores, more than one pharmacist is staffed. at walgreens, we also keep track of mistakes that happen, as opposed to what hte lady interviewed on the video said (though i dont recall if she was a rep from walgreens or not).
3) we (walgreens) do have a system that logs mistakes, who did the mistakes, and courses of action to take in the future to limit a similar mistake from happening again.
Posted by: cris | Apr 3, 2007 4:43:52 PM
It always amazes me we people outside of any occupation attempt to explain another. Do police officers drive around all day shooting the good guys? Do teachers only have sex with their students? The answer is NO, but this is the stuff that gets reported.
I'll admit that mistakes do happen, but they are less often and less severe than your story reports.
As for teenage technicians working in the pharmacy, I started as a technician when I was 16 and will graduate in June as a Doctor of Pharmacy. Everyone has to start somewhere! Teenagers are great employees and can handle working in a stressful work environment. A pharmacist cannot complete all the steps needed to fill a prescription. Did Brian Ross and Justin Rood do everything for their story or did they need other people to help? As for reporting errors, some pharmacies report to their company not to the state.
Posted by: Jeff Steckman | Apr 3, 2007 4:54:21 PM
I am a CPhT working for Walgreens. I have been employed there for apporximately 2 years, and in that time I have NEVER worked with a teenage employee who would be better off flipping burgers. I have however worked with many dedicated pharmacy technicians that work themselves to the bone in the face of the GEBERAL PUBLIC, which is the most unforgiving, thankless, tactless and unreasonable entity known to this planet. I am deeply dissapointed in ABC for not properly doing their homework and understanding the role of technicians in the pharmacy. First, it is completely illegal for a pharmacy technician, CPhT (CPhT is the professional designation for a Rx tech who is nationally certified)or not, to counsel patients in any way on their medications. Your story about the coumadin / aspirin interaction is blown very far out of proportion. The individual ringing up patients at the counter is 99% of the time a pharmacy technician, and probably a junior tech at that. It is completely unreasonable to expect them to inform the patient of the dangers associated with mixing prescription drugs and OTC's. Please, let's have the world at large take just a little bit of responsibility for what they decide to put in their bodies! And don't go trying to blame the Pharmacist, who's probably tied up with a million other responsibilities. The public needs to wake up and start realizing that we cannot always hold everyone's hand. That's why we place warning labels on prescriptions. .
Posted by: Jason | Apr 3, 2007 5:08:36 PM
I have been a pharmacy technician for almost 7 years. In the whole time as a tech, I have never witnessed an unlicensed individual verify any prescription.
20/20 has inaccurately portrayed the profession of pharmacy. They need to take another look at what really goes on, on a daily basis. They need to take a closer look at the number of times pharmacists intervene positively, which save patients lives.
Doctors make mistakes and the pharmacist is there to catch those mistakes. That is a positive influence on a patients life that you have neglected to portray. Trust your pharmacist as you would any health care professional. This is very disappointing.
Posted by: Joe | Apr 3, 2007 5:45:17 PM
I consider it my personal responsibility to know as much as possible about all of the medications I take, before I even take the first pill. I educate myself, because I can rely upon myself.
Mistakes happen at pharmacies. I have only had it happen to me once in 30 years, and it was corrected immediately upon bringing it to the pharmacist's attention. I have had pharmacists catch multiple problems before they arose, however, and they have always gone out of their way to help me when I have had questions or needed more intensive advice.
It is lamentable that mistakes occur, but given the pressures these people work under, it behooves patients to educate themselves about their medications. It is important for patients to know the dosage of their pills before the doctor even hands them a prescription.
Posted by: Amanda | Apr 3, 2007 6:20:54 PM
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