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New Pharmacy Error Found at Walgreens

April 18, 2007 11:28 AM

Pharmacy_update_nr A seven-year-old boy from Modesto, Calif., who ended up in the emergency room, is one of more than a dozen cases of serious pharmacy errors at Walgreens drugstores reported by readers and viewers in the wake of an ABC News investigation of the problem posted online and broadcast last month.

Walgreens has confirmed the incident.

"His legs were shaking, he was getting delirious, cold and shaking. I kept thinking why is this happening?" the boy's mother, Diane Ramirez, wrote in a letter to The Blotter on ABCNews.com.

Ramirez said she filled her son's prescription for a drug called Tegretol-XR, which was prescribed to treat her son's mental health problems, on March 15 at her local Walgreens. But her child's condition worsened, and his doctor told her to increase the dosage.

It was not until a friend suggested she view the recent ABC News "20/20" report on pharmacy errors on The Blotter on ABCNews.com that Ms. Ramirez thought to double-check the prescription.

Click Here for Full Blotter Coverage.

To her horror, instead of Tegretol-XR, Walgreens had given her Toprol XL used to treat high blood pressure in adults (pictured above).

"My son had been taking the wrong pills for almost three weeks. I immediately took him to the emergency room where he was evaluated. The doctors told us that if we had not caught this in time, our son would have collapsed because the medication was making his blood pressure drop," Ms. Ramirez told ABC News.

Ms. Ramirez went back to her local Walgreens, where, she says, "a red-faced pharmacist apologized over and over. He said he didn't know who had filled the prescription and gave us a new bottle of the correct medicine. The pharmacist refunded our $20 insurance copayment and asked us to return or destroy the wrong pills."

When contacted by ABC News about the Ramirez case, a spokesman for Walgreens acknowledged the error, saying the pharmacy manager at the Modesto Walgreens had filed an internal company error report about the case last Friday.

In a statement to ABC News, Walgreens said the prescription had been filled by a pharmacy technician and checked by a pharmacist. "As a result of the error, procedures were reviewed with the Pharmacy staff" at the store, the company said.

Walgreens appears to shift some of the blame for the error from its own pharmacy staff to the young boy's doctor. "We found the prescription was handwritten by the doctor and unfortunately misread by our staff."

"This is a case where electronic prescribing could have avoided confusion between two medication names that looked similar when handwritten," the company statement said. 

"I'm angry and upset, particularly at Walgreens attempts to blame our doctor. What you showed on '20/20,' it's happening here in our neighborhood. We were shocked and furious to find out it had happened to us," Ms. Ramirez said.

"It's disappointing but not surprising," University of Illinois Professor Bruce Lambert, a specialist in studying medication errors, told ABC News in response to the Ramirez case.

"Confusion between drugs with look-alike and sound-alike names, such as Toprol and Tegretol, is a well-known problem," Lambert said. "The FDA issued a warning to pharmacists in October 2005 of the potential for mix-ups with these two drugs."

The "20/20" pharmacy investigation found there were no federal regulations, and only a few states require drugstores to report pharmacy errors. There are also no federal standards for pharmacy technicians, who can often be high school students with minimal training.

"Retail pharmacies have their own internal error reporting systems, but they have fought efforts to require them to publicly disclose the information, claiming proprietary and privacy concerns," said Lambert. "Access to this data would be a valuable resource to study and prevent future errors."

In the latest development, after ABC News contacted Walgreens to ask about the case, Ms. Ramirez said she received a phone call from a Walgreens  representative who asked how her son was doing and offered her a "settlement," which she says she politely refused to discuss.

"The doctors at the emergency room told me I should report this, but I had no idea who to tell. That's why I wrote to ABC," Ms. Ramirez said.

April 18, 2007 in Pharmacy Investigation | Permalink | User Comments (53)

User Comments

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While I do not blame the doctor in this case, I do agree with the pharmacist that protocol can be revamped to reduce human error. I have often taken hand-written prescriptions to my pharmacist and seen a frustrated reaction as the person attempts to decipher my doctor's handwriting. The pharmacist often asks me to verify the prescription because the penmanship is so poor. Since the hand-written prescription is on letterhead with a phone number, others at the pharmacy sometimes call the doctor to clarify the prescription and voice displeasure with his illegible "chicken scratch."

Posted by: Ellen | Apr 18, 2007 1:23:40 PM

The doctor may have written a little illegibly, but the pharmacist should have know that the medicine was improper for a 7 year old to take. They input your personal information into their system and should have know the prescription was for a 7 year old child. My doctor accidentally printed a prescription for an antibiotic in the form of very large pills one time for my 7 year old son. I unknowingly made my son take this medicine one time and then decided to call - and yes, it was a wrong prescription also. It was not Walgreens, but to me, if they as for a D.O.B. to confirm who the prescription is for, a pharmacist should be able to tell when a prescription just doesnt seem right for that age.

Posted by: Concerned in Texas | Apr 18, 2007 5:45:11 PM

This happens too much and unfortunately the pharmacy do not take responsibility for the mistakes. I understand we are all human, but when a life is in the care of someone else's hands, then it needs to be double and triple checked. I have had similar problems at a neighborhood Rite-Aid and it scared me that if I had not checked into the medicine online I would have been very sick. Our health care seems to be getting more and more expensive and the care is getting worse. Why is this?

Posted by: Linda | Apr 18, 2007 10:06:51 PM

Walgreens has got to be kidding. The pharmacist DIDN'T ask WHY blood pressure medication was being prescribed for a 7 YEAR OLD BOY? COME ON!!! They didn't check! Period.

Posted by: Greg | Apr 19, 2007 11:16:36 AM

In no defense to the pharmacist. Although not as common to the "normal" individual, toprol as well as toprol XL, a beta-blocker, as well as other blood pressure medications are given to children as young as 5 up to the age of 12. Sometimes these drugs have an effect on certain mental conditions like ADD and ADHD. The pharmacist could have easily taken a quick look at the profile and seen tegretol and some other "mental condition" medications and not given it another thought. it's not as uncommon as made out to be. It was a mistake, it happens

Posted by: Michael | Apr 19, 2007 4:39:54 PM

Once the pharmacist receives the perscription it is their responsibility to make sure it is the right dose and medicine for the patient. If it is not their responsibility then who is responsible for filling the right prescription? I think pharmacists have enough parmacy techs to call and ask doctors about medicines. The pharmacists try to diagnose patients and to justify questionable medications when instead they should check with the person who is prescribing the medication. It doesn't matter wether the prescription is hand written or not pharmacists can check on prescriptions. Also, patients should reasearch what they are putting into their bodies.

Posted by: barb | Apr 19, 2007 6:57:11 PM

As a pharmacist I can tell you everyday I fear making an error and I personally refuse to work for a high volume chain for just that reason. I recommend to my friends all the time supermarkets/Target/walmart or any pharmacy that doesn't have a line of waiters going out the door. Simple math: an RPH filling 400 scripts in 12 hrs has less than 2 minutes a script, while I do 80-100 for an independant and feel fortunate that I have time to counsel any patient that is open to it. Face to face with the patient or parent is the fourth check and I am please to do it.

Posted by: jordan | Apr 19, 2007 8:00:11 PM

The first rule I give my technicians (all but 2 are nationally certified-an ABC news factual error) is that if you are not sure--call the MD. The 2nd rule is that we are not a McDonalds (more on that some other time). Still, even a drug that looks right can be still be wrong. MD's make prescribing errors and write illegibly and frequently use drugs outside normal evidence based prescribing practice. While many are quite nice when you call for clarification or to question a drug or its dosing, many MD's and their staff are very rude; a "how dare you question me" attitude. Coupled with the general public's near ignorance about chemistry and medicine except they need only show up and get pills, this is a three fold recipe for disaster. There is a reason we ask if there are any questions before we sell a medication. Were it up to me every first time drug for a patient would require counseling, whether it was wanted it or not. But all too often, the patient says "no" because they are in a hurry (what do you mean I have to wait 25 minutes?!) and mis-reads like Tegretol-Toprol-Topomax or trazodone-tramamdol occur. The responsibility lies with all three: physician, pharmacist AND the patent. It took you 3 weeks to figure it out the misread, Diane? Are you illiterate? Did you not READ the bottle Diane? NO! You didn't. You assumed...for 21 days. And as I tell my staff, if you don't check and re-check and you don't verify when you are uncertain, you've only yourself to blame. P.S. Hard to read Rx's is not an isolated problem. Read Pharmacy Times magazine and check out the illegible Rx's sent in from across the nation. Most you'd never get without looking at the answers.

Posted by: Dr. Phil Hopkins, Jr, RPh | Apr 19, 2007 11:03:37 PM

AS A SR CPHT FOR WALGREENS ( SENIOR CERTIFIED PHARMACY TECHNICIAN) I UNDERSTAND THE IMPORTANCE OF SAFETY IN THE PHARMACY SETTING. HOWEVER, I DO NOT THINK MOST PEOPLE WANT TO PLACE AT LEAST SOME OF THE BLAME WHERE IT BEGINS. WITH THE DOCTOR.
I SEE PRESCRIPTIONS DAILY THAT ARE IMPOSSIBLE TO READ. THEY ARE SO EDUCATED...WHY DO THEY NOT SEE THE IMPORTANCE OF WRITING SOMETHING AS IMPORTANT AS A MEDICATION AND DOSAGE FOR THEIR PATIEN CLEARLY? THEY LEAVE IT TO PHARMACIES TO DECODE THIR CHICKEN SCRATCHING, AND MAKE THE CORRECT DECISIONS. SIMPLE...WRITE CLEARLY.
ALSO, DO PEOPLE REALIZE HOW OFTEN IT IS A DOCTOR THAT WE HAVE TO CALL TO CONFIRM, CHANGE OR INFORM THEM THAT THE MEDICATION THEY PRESCRIBE IS WRONG? OBSOLETE? DOESNT COME IN THE STRENGTH THEY PRESCRIBE? PATIENT CANNOT TAKE FOR ONE REASON OR OTHER? DOSAGE IS INCORRECT?
I AM NOT SAYING THAT ANY MISTAKE BY ANYONE IS OK... IT IS DEFINATELY NOT, BUT LETS TAKE A LOOK AT THE WHOLE PICTURE. THINK OF JUST HOW MANY PRESCRIPTIONS ARE FILLED PER DAY, BALANCE THAT WITH THE ERRORS.
WALGREENS IS NOT ANY MORE PERFECT THAN ANYONE ELSE, BUT BE FAIR...WHY DOESNT ANYONE MENTION HOW MUCH MONEY THIS COMPANY HAS SPENT IN SAFETY? OR THE FACT THAT WE DO KEEP TRACK OF ERRORS, REPORT THEM, AND INVESTIGATE?THAT STAFF IS MORE HIGHLY TRAINED THAN THE OTHER COMPANIES?
IM SORRY IF I SEEM DEFENSIVE. BUT I HAVE BEEN IN THIS JOB FOR QUITE SOME TIME, AND I CAN TRUKY SAY I WOULD NOT WANT TO WORK FOR OR HAVE MY PRESCRIPTIONS FILLED ANYWHERE ELSE..WHETHER I WORK FOR WALGREENS OR NOT. I AM THERE...I SEE THE STEPS TAKEN DAILY TO TRY TO PREVENT ANY ERRORS, AND I SEE A COMPANY THAT TRULY DOES PUT PATIENTS AND THEIR SAFETY FIRST.
PERFECT? NO.... BUT CONSATANTLY TRYING TO IMPROVE. LETS BE FAIR AND TRULY LOOK AT THE COMPANY. NOT JUST LUMP THEM IN WITH ALL THE OTHERS. I GUARANTEE YOU WILL SEE THE DIFFERENCE.

Posted by: BJ | Apr 19, 2007 11:50:43 PM

Everyone is missing the most important protection against these type of errors. Take the responsibility to know what the medicine is suppose to be and read the label. Then if you have a question ask and if needed ask again.

Posted by: mm | Apr 20, 2007 10:30:40 AM

I have just read all the responses and every statement made about checking prescriptions is everyone's responsibility. However, I have to agree with Dr. Hopkins the real responsibility should be the person who picks up or administers these medications. Let's face it we are all human and we will make mistakes. Even if these prescriptions were transmitted electronically there is still room for error.

Posted by: Carol | Apr 20, 2007 12:35:26 PM

I just wish that the mother of the Virginia killer had given him the wrong RX when he was a child and that he would have died then 32 other people would be alive today to debate this issue.

Posted by: Chris | Apr 20, 2007 6:31:05 PM

I have worked as a Sr. Certified pharmacy tech for 10 years and am now in pharmacy school. I agree with everyone taking a little more responsibility for themselves. Doctors are notorious for writting like crap and even with all the errors that can happen, do you think they try any harder to make it legible? Nope. Then try telling a person who wants their pills handed strait to them, right that second, that their Dr. wrote something with no strength or you cant read it. Its "gimme your manager". People have become spoiled and expect everything now or else they throw temper tantrums like two year olds, then these big corprate chains reward them for their inconvience. What are we teaching? People need to take a second and realize that filling rx's take time especially when you want them correct! In the store I work at we did up to 1100 scripts daily. So dont rush it, slow down, take a breath and come back later for your script, it will be there when you get back. I promise!

Posted by: amanda | Apr 20, 2007 9:55:27 PM

I bet the mistakes compared to the rxs filled ratio is super low. Can horribley bad things happen. YES! but blowing it out of proportion dosent help. Educate the consumer on how to double check the meds themselves as well. This can help. How can a pharmacist help you if you cant even help yourself? Educate educate educate. Cant stress it enough. Mass belittling cant do any good if you ask me.

Posted by: Angel | Apr 20, 2007 10:09:55 PM

I tried to get a persciption filled by walgreens. I tried to explain to them that my Aunt had tricare as well comunitycare. and she had told me that their would be no charge or mabe $3 or $9 charge they told me it was $47.00. My Aunt is 85yrs. and she has been taking this medicine a long time and she never has to pay. They were very condisending to me and basicly told me that the way it is. I ask for my money back and they did in a real huff. I went to cvs and it was $38.00 I said no. I went to walmart and finally someone ckecked and ask some ?s and I got her perscriptions for $0 . It makes me wonder with all this technical stuff and if some one does not ck all the facts how many people are getting ripped off because some so called expert told them. I feel bad for the elderly that have no one looking out for them. I wonder who is going to be their for me when I get old?

Posted by: Toni Creighton | Apr 21, 2007 12:33:28 AM

I am so glad that the posters here finally mentioned the consumer's responsibility. Now we've covered all of the bases. Remember people what kind of world we live in and it is we, the consumer, who is to blame 100%. We demand instant service in this "I want it now" society. Like the good doctor mentioned, "this is not McDonalds". If all of us would slow down a bit we might realize how much time, effort, heartache and money we would save. How do we take ourselves back to a time when we cared about our "product" and our fellow neighbor? Indeed, everyone was at fault and we have all answered the questions as to "why" it happened, this was the easy part. The hard part is following through with the answers and everyone taking better care and more time at the time of "service" yes, and "we" the consumer needs to "let" this take place. So, be patient and you will be rewarded with the best service you've ever had without the stress and agony of hurrying our providers and then spouting off at them when mistakes happen. Pass this on so we can be a better society.

A, Christian, wife, and a mother of 4.

Posted by: Susan | Apr 21, 2007 9:43:31 AM

I have worked for Walgreens now for three years. It is a great company! I believe that any missfills are tragic and should not happen, but come on now, that isn't possible. No matter what education level someone has, they are still people, and people make mistakes. If you are going to take a medication, take responsibility for yourself. Know what you are taking and what it does to and for your body. Do not always place your life in other peoples hands because they are just that, people. Looking at perscriptions all day long, it happens. Doctors write horribly and even after they passed the "write legibly" law MDs still do not write legibly. Not to mention CVS, WalMart, Target, Mom and Pops, Eckerd, and all other pharmacy chains also have missfills. Lets be realistic here, they only pick on Walgreens because they are the dominant chain right now. We have to pull companies down when they are up. I am sorry to anyone that was ever hurt because of someone elses error, but you cannot just blame one person in this case. It is your fault, the pharmacies fault, and more than likly your doctors fault. AND INSURANCE HAS NOTHING TO DO WITH THE PHARMACY. We act as a 3rd party as a convienience for you, the customer. So for all of you out there that are posting comments about insurance, your barking up the wrong tree.

Posted by: Christina Baptist | Apr 21, 2007 1:27:09 PM

My comments are not intended to support or criticize the pharmacist involved with the issue. But this problem brings up a bigger issue which can help minimize such errors in the future.

ABC news does a great job of making the public aware of problems in the community, and opening the eyes of corporations, or individuals involved with problematic issues. It would be beneficial for all, if ABC news and/or 20/20 can also do a report on television and online how illegible most prescriptions are, and how difficult it is for pharmacist to read the script. Healthcare professionals need to work as a team. If your co-worker submitted a handwritten report that looked like "vvv vvyvvy vtvvv..." would you be able to understand that they wrote "The finical situation of the company is..." No you would not. Doctors, nurse practitioners and other prescribers write for things that can be deadly if used incorrectly. Pharmacist get up to 50 prescriptions to fill in an hour, if they spend most of their time on the phone or trying to decipher a script how much time do you think it will take them to fill one prescription if they still have to check for drug interaction, the appropriate dose, and other things? Majority of patients want their prescriptions in 10 minutes, one minute their at the drop-off window, then two minutes later they are asking for their medication at the pick-up window. Pharmacists are HUMAN beings, and no machine would be able to decipher that sloppy hand writing as well. It takes 30 extra seconds to write legibly, but between 5 minutes to 3 hours to contact a busy doctor to ask what he/she wrote for. States such as Washington passed a no cursive rule, but doctors do not always follow it.

THE MAIN POINT IS: IF THE NEWS MEDIA CAN BRING ATTENTION TO THIS ISSUE OF ILLIGBLE PRESCRIPTONS, THEY WILL BE ENHANCING HEALTHCARE SERVICE.

Posted by: JJ | Apr 21, 2007 1:54:59 PM

it is certainly the responsibility of everyone in the chain to be responsible, including the consumer. i pay attention to what my doctor tells me and what he writes down. if it's not clear, i ask. walgreens, as well as all other pharmacies, usually give you a printed description and directions and describe what the drug is used for. pay attention! it's life and death for you and your family!

Posted by: steve | Apr 21, 2007 2:16:12 PM

and the hother should of read the label before she left the drugstore. I always read them before i leave.

Posted by: STEVEN EPSTEIN | Apr 21, 2007 7:02:50 PM

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