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New Pharmacy Error Found at Walgreens
April 18, 2007 11:28 AM
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.
THE BLOTTER RECOMMENDS
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)
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Bravo steve! As a mom to two kids, I would never give something to my kids without reading what it is, even if it is something recommended by my Dr. Look what happen to all those pregnant women who were given Thalomid for nausea and their babies were born with horrible birth defects. These are chemicals we are putting into our bodies not candy, take more care!
Posted by: amanda, mother of two | Apr 21, 2007 10:29:53 PM
As for the insuance price issue, it sounds like you need to call and ask your insurance company whats the deal due to the fact that with Walgreens we submit what you are getting to them and they quote the price NOT Walgreens. We bill the insurance company for convience but do not argue with them over your price thats your job. Also, were the insurance cards presented or just the fact that your aunt had two insurance companies? An insuance card is just as important as having to show a credit card. You wouldnt walk into a grocery store and just say I have visa, bill it. There are important numbers on that card that can definately make a change in the price. Sure we would like to call every insurance for every elderly person who comes in the store, but try living in Florida where 3/4 of your clientell are seniors and shouldn't be walking around on their own let alone driving to the pharmacy and handling their own finances. It's sad, but there's definately a bigger issue here over and above bad customer service.
Posted by: amanda | Apr 21, 2007 10:42:01 PM
In response to the lady who was picking up prescriptions for an elderly relative with two insurance companies that included Tricare, I can respond.
Many pharmacies are not equipped to accept more than one insurance per prescription. Unlike doctor's offices that send all the insurance information to a billing office, pharmacies generally input the information on the spot. It is far too time consuming to have to figure out which is the primary insurance, which is secondary and what the final amount due will be. Remember, they still have to decipher sloppily scribbled scripts, check for drug interactions and verify accuracy while working with a continuous influx of new scripts that need to be filled.
If your aunt has Tricare, along with another insurance carrier, the Tricare is considered secondary insurance. All she needs to do is submit a claim to Tricare and they will send her a refund check for the amount she paid after the primary insurance paid their portion. The checks are sent quickly.
Posted by: Laura | Apr 22, 2007 9:30:17 AM
As a parent of a mentally ill child I understand the frustration the parents are feeling. However, I always check the bottle and the pills in the bottle before I leave the pharmacy. I believe that it is all three parties that are ultimatly responicable for this mistake.
Posted by: landra | Apr 23, 2007 4:28:23 PM
Yup, walgreen submits an internal report/investigation then hides it.
Yup, the pharmacist and his (or her) assistant don't pay enough attention to prescription or customer.
Yup, the doctors' writing is illegible.
Yup, mom and dad don't look at the label.
Yup, everybody's offended at being questioned.
Yup, nobody accepts responsibility for their part.
I have perhaps over-simplified this seemingly complex issue, but through the haze of everyone blowing smoke to avoid being looked at...the word responsibility will not be ignored. No one is responsible anymore, its' always the other guys' fault.
I've seen 5 year old children accept responsibility, learn and move on.
Posted by: Gary | Apr 24, 2007 11:30:18 AM
As consumers of health professionals, we should insist on either a typed prescription or a legibly written one from our physicians. If a pharmacist or technician then makes a mistake, he cannot use the excuse that the handwriting was confusing.
Posted by: Pat | Apr 24, 2007 3:18:31 PM
I have used Walgreen's Pharmacy for many years. Whenever I pick up a prescription I verify that the prescription is correct ie drug and dosage. Each prescription comes with a complete description and the known side effects. I always file the most recent information. Obviously the mother didn't read the information that came with the prescription for her son.
Recently, I had a new prescription filled for my grandson. After 3 days on the medication, not only was there no improvement, his condition worsened. I immediately took him off the medication and called the doctor. It wasn't that the prescription was incorrect, it was that his system couldn't tolerate the medication.
Know what the prescription is supposed to be. Don't leave the doctor's office without knowing this. Then check when you pick-up the prescription at the pharmacy to verify that the prescription is correct. With any new medication be aware that different drugs can have different results with different people. Be a responsible patient and consumer.
Posted by: kb3245 | Apr 24, 2007 10:53:08 PM
I have worked as a licensed pharmacy technician also. The store I worked in was a chain drug store in a small town. The pharmacists were very diligent about the accuracy of the prescriptions. They would call the doctor and verify the prescription if needed, or take any measure to make sure the medicine was filled correctly. Unfortunately, this takes time. What do you think they got it return for their efforts? I'll tell you. Customers standing in line glaring at us because they were having to wait 15 minutes or more for their medicine. People stomping off in dusgust because they had to wait for us to call the doctor about a script missing information. Somehow this was our fault. We lost customers to other pharmacies because we tried to do things right and take the time to counsel people. The more you help one customer, the more time it takes away from the next one. Pretty soon you have people who are very angry because their medicine isn't ready instantly. I actually saw one customer reach across the counter and grab the pharmacists arm because he was tired of waiting on his script to be filled. No, there is no excuse for error. But customers in general put tremendous pressure on everyone working in the pharmacy to be faster and faster because they don't want to wait. I am proud of the reaction of the pharmacists I worked for. They would not comprimise on accuracy even when they were losing customers because you could go across the street and get your prescription filled 5 minutes quicker. They don't realize what they were giving up. People filling their medicine who cared very much about their customer's health and well-being. In return, they were cursed at, yelled at, glared at, and told they were slow and fine, I'll just take my scripts somewhere else. I know my comment is one-sided and realize this is not the whole problem. But, customers themselves could go a long way toward solving this problem if they would just allow more time for the scripts to be filled without getting angry.
Posted by: Deborah A Barr | Apr 25, 2007 9:16:37 AM
parents....here's a novel idea. While at the doctor's office with the child, ask about the medication being prescribed.
When you get to the pharmacy, make sure sure to check the bottle for the right med. i've been doing this for years and just consider it good parenting. Humans make mistakes! Take ownership for your child's protection.
Posted by: john | Apr 25, 2007 11:53:22 AM
I agree 100% with "Concerned in Texas." He/She basically said everything I was thinking. If they had a hard time reading the prescription that the doctor wrote, they should have CHECKED IT. It's absolutely ridiculous.
Posted by: Nina Nealon | Apr 25, 2007 12:57:20 PM
What is disgusting to me is how all of you people out there think it is ok for someone to neglect resposibility. Give me a break. Yes the pharmacist made a mistake, but the Doctor should write clearer and the patients should know what they are putting into their childrens body. How many people feed their children fast food for breakfast, lunch, and dinner? How many people bath their infants with adult shampoo or soap? How many people let their 5 year old smoke? Oh most don't. Could that be because we all know what affects this would have on our children. Everyone is at fault here. Quite pointing fingers and lets fix the problem on all ends. Doctors write legibly. Pharmacists get your heads out of your butt. And parents, learn about the meds your children take.
Posted by: Christina | Apr 25, 2007 4:04:19 PM
Just reading the comments from some of the pharmacy techs that have written in, I don't think I would want you to fill my prescription. You can't even spell your words right, so how can you possibly fill a script right? Maybe before I have any prescription filled at any pharmacy I should have them spell for me. I can see why the wrong medication is given, if you can't spell and punctuate properly, you surely wouldn't know what medicine to put into a bottle!
Posted by: Anonymous | Apr 25, 2007 6:50:42 PM
After reading each coment posted, I realized that not one posting had mentioned that the Pharmacist had counseled or offered counseling to the patient. In the state that I practice in, it is required BY LAW that the pharmacist COUNSEL on every first-time prescription and OFFER counseling on refills. Mistakes like the Tegretol- Toprol could have have been caught when the pharmacist ask the patient "What did the phycisian tell you this medication was for?" or "What is the phycisian treating?". These are example questions that the pharmacist should ask during counseling.
Pharmacist graduate now days with doctorate degrees (PharmD) and are highly educated concerning drugs. They are the people that you should be asking questions and talking to about your drugs.
The one best thing you can do when filling a presciption is to "talk to your pharmacist". If they do not offer counseling, than you should demand it.
Posted by: Dr. Rapp, PharmD | Apr 25, 2007 11:01:14 PM
I have seen the report by 20/20 concerning prescription errors. I feel any error which occurs in a pharmacy is tragic and it definately has the potential to hurt someone. It is every pharmacists worst nightmare to even make an error.
As a Walgreens pharmacist, I viewed the tv presentation with a sense of misrepresentation. I have worked for Walgreens for over 15 years. In this time period there have never been any quotas as to how many prescriptions I must fill. In working at a retail pharmacy it is totally unpredictable how many Rxs will be done per day.
In my tenure with Walgreens I have also seen how the company has evolved. I have seen the technology the company has invested in for the prevention of errors. I have seen the programs intended to educate the staff and improve service. I have also seen how customer service still remains its number one priority.
This tv presentation supposedly went undercover recording several pharmacies, however, only portrayed one as the villain. Based on the pharmacy layouts it is clear to me which pharmacies were which. To an unfamiliar viewer the tv program made it seem that those undercover videos were all at Walgreens. One misrepresentation of these videos is when customers are asked to sign at the counter when receiving their prescription. I have never seen that happen at a Walgreens.
First, I would like to say that all pharmacies, regardless of company, are all human based. This statement means that there is potential for error at any pharmacy. Secondly, There is a national test which must be passed in order for technicians to be certified to work in a pharmacy. Thirdly, there are age restrictions for technicians which are set by state pharmacy boards.
The tv program also stated that errors are not tracked by pharmacies. Walgreens does track errors and takes any error that occurs very serious.
Working in a pharmacy is a very stressful profession. As a society we expect things to get done fast. We expect fast service almost everywhere we go. Our society does not want to wait in lines. We are all inpatient. We measure a good pharmacy based on the speed it takes for the prescription to get ready. We get angry when the Pharmacist says we cannot fill the RX until we contact the Dr for whatever reason.
In response to the insurence issue raised ealier. Pharmacist should focus on filling Rxs as accurately as possible. Perhaps the pharmacy staff could help with minor method of payment issues, but, ultimately the patient should be prepared to deal with their own money or insurence issues. Just as when we go shopping for other things.
I feel this tv program had many misrepresentations and unfairly depicted Walgreens. Even though I feel this way, there could be positive outcomes to this program.
I am sure Pharmacist in general will take this show serious and work to prevent any errors. I am also sure some patients will learn to appreciate pharmacy as a profession instead of a fast food type of service.
Posted by: Mtz Rph tx | Apr 26, 2007 2:31:19 AM
To all
I'm a native of Houston Tx who is also a diabetic. I must add I was a healthy attentive diabetic, until I was given the wrong medicine. I am in the same situation as Diane Ramirez's son. Walgreens gave me Ablify instead of, Actos!!! I had taken it for 28 days!! and discovered the exact symptoms along with others disturbing symptoms. I also lost time at work and my sexual desire. My wife became depressed because we DID not know what was wrong until 28 days, later. I've gone to emergency thinking I was going to die along with losing my ability to communicate. I lost weight, I could not sleep, I could not eat, I could not talk, I could not walk, I could not comprehend, I could not work I could function along with all the other side effects Ablify offered, trust me I encountered every symptom. Luckily my wife asked to look at the medicine container and noticed TWO prescriptions labels typed on ONE MEDICINE BOTTLE. The pharmacist NEVER EVER noticed the error until the night my wife called and brought it to their attention. I too have filed a claim against Walgreens. Actually I'm still not feeling like my body should. For the record Walgreens may call this negligence but they should call this to their attention and hope this does not consistently happen as it is at the present. Who's to say this could not affect me in the future!!
PS wishing your son well Ms Ramirez
Mr. Eugene Fuqua
Posted by: Eugene Fuqua | Apr 27, 2007 8:28:59 AM
I am a Sr. CPht who works for Walgreen's. I think that any error that happens is a worst nightmare for anyone who works in this field, whether minor or major. However, I must agree with many of the previous comments about patients and cutomers who treat pharmacies as if they were fast food restaurants. Do you really want your medications done in the same time it takes to get a Happy Meal? That is not enough time to read your prescription, scan it into our system, enter the prescription (which often means deciphering the doctor's handwriting), have a Pharmacist review it, fill the prescription, and have the Pharmacist verify that it is correct. All of these steps take place regardless of whether it a box of birth control pills or a chemotherapy medication, and all of these steps take place while other orders are worked on. For every parent out there who gets impatient because the pharmacy is taking its time to fill your child's prescription, I say that you should be glad that they care enough to make sure that it is right. And because we are all human, please check your medication and ask any questions that you may have. Walgreen's uses cutting-edge technology to ensure that everything is accurate, but ultimately we are all human.
Posted by: Lisa | May 5, 2007 11:55:38 PM
The real cause for all the errors made is speed.Companies demand you not keep the patient waiting.Answer that phone within 3 rings.If you can not fill 200-250 scripts a shift you are too slow.Yon need to be repleaced by a younger faster pharmacist.Endless articles pointing to ways to stop error.BUT NO ONE EVER SAYS SLOW DOWN!Airline pilots fly only so many hours and over the road truck drivers can only drive so many miles per.But pharamacists, good parmacists,the more they fill the better.If only one could fill 350 to 400 per shift with on lunch break,no tech support,no cashier, and oh yes ,I almost forgot.Let's throw in a drive-up window to rive up the stress.Let's teach each and ever patient to challenge every co-pay,to produce at least 6 expired HMO cards,to protest a waiting period over 5 minutes,to fail to provide all necessary information (well ,I'm in the compter}and lets have the patient go to the wrong pharmacy and demand a refill. Am I glad to be retired?
Posted by: mike lesser | May 6, 2007 12:34:45 AM
s
Posted by: Lisa | May 6, 2007 1:07:12 AM
im so sick and tired of you guys pharmacys make mistakes i didnt even hear about the two cvs eckerd pharmicists who wouldn't give a woman who was raped plan b because they thought it was wrong you guys blantly went after walgreens
Posted by: geoffrey | May 11, 2007 12:47:57 AM
@post by Lisa -
how old was the girl who was raped? If she's over 18, she could show photo ID and get it. If not, I'd recommend her getting her parent or friend to purchase it for her.
Thoughts:
are you sure they thought the plan B was "wrong"? As far as im concerned, a Rph's feelings about medications should only be made if the medication is wrong for the patient. Their own morals/ethics is not meant in a 'public pharmacy.' In a private one, yeah sure they can do whatever they want but not in an Eckerd.
Most patients are stupid and don't care what it says on the Rx, they just want their meds ASAP for cheap. I say, "if you want fast food, McD's is across the street. If you want your medication filled incorrectly but fast, you can take your Rx elsewhere."
half the Rph's i work with care about the patients' correct medication and the other half care about getting the medications out FAST! I say, "if you cant read it, call." However, to the Rph's who dont work accurately, "get a new job."
Posted by: S-word. | Sep 16, 2007 4:14:29 AM
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