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Drugs & Adverse Effects / Death by Prescription
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Perhaps no one in health care is more acutely aware of the potential harm of prescription drugs than pharmacists. Yet, pharmacists say little attention is paid to the difficulties they face in today's complex health care environment.
The Leesburg Pharmacy in Leesburg, Va., is a case in point. On a recent afternoon, half a dozen patients were lined up behind the counter waiting for their prescriptions to be filled; others milled about the store. A series of bins with prescription slips and medications formed a queue along the green formica countertop. Forty-nine prescriptions were in one stage or another of preparation. "And this," said Greg Chase, the chief pharmacist, "is a slow day."
Leesburg is an independent pharmacy and, like pharmacies around the country, its profits are being squeezed by lowered reimbursements from managed care companies. So it makes up the difference in volume. The pharmacy fills about 300 prescriptions every day, a 50 percent increase over that of three years ago, said the store's owner, Bruce Roberts. He said that leaves little time for pharmacists to talk to patients about how to take their medication, something experts say is essential if drugs are to be used safely.
"The medications have become much more complex, and the interactions among these complex drugs is greater than it was in years gone by," Roberts said. "With managed care and pharmacists being stretched to the limit, there is just no way that you can provide the service that we really need to be able to educate the populace as to the dangers of drugs."
Still, Roberts is trying. He has set up a private consultation counter for patients who have questions. He has purchased a robot, at a cost of $175,000, that can dispense the 200 most commonly prescribed medications, a system that not only allows pharmacists to do more counseling but can also cut down on mistakes. And he has diversified, selling gifts and offering lactation consulting and other services so that he can afford the salaries of his three full-time pharmacists.
That is a relief to Chase; he came to Leesburg Pharmacy two years ago from a chain drug store, CVS, where three pharmacists filled 600 prescriptions every day, and often worked 12 consecutive hours to do it. "You've gone four to five hours without even a chance to go to the restroom," he said, echoing the complaints of his colleague, Joseph, who previously worked at the Rite Aid chain. "Your mind is fried."
Officials at CVS, which owns 4,100 drug stores in the United States, and Rite Aid Corporation, which owns 3,800 stores, say they have no evidence that more mistakes are being made. But they are concerned about workplace pressures, and are taking a number of steps, including greater use of robots, to ease the burden. As members of the National Association of Chain Drug Stores, the companies are also sponsoring research by a psychology professor at the University of Cincinnati who is examining ways to reduce pharmacy errors.
The professor, Tony Grasha, said in an interview that mistakes occur when psychosocial factors, such as stress at home, combine with a higher workload. Dr. Grasha said his studies show that errors are rare, about one-half of 1 percent of all prescriptions filled, and that those that pose a danger to patients are rarer still. But, he added, with the number of prescriptions growing, mistakes are a serious concern.
"It is a tiny fraction percentage-wise," Dr. Grasha said, "but when you are filling three billion prescriptions a year and are anticipating four billion by the year 2005, then even a very small percentage is a lot."
Some state pharmacy officials are also worried. In addition to the action against Rite Aid in Washington State, officials in another state, North Carolina, are trying to force drug stores to cut back on pharmacists' hours and to require lunch and bathroom breaks in an effort to improve safety.
The North Carolina Board of Pharmacy has also decided that when a pharmacist who fills more than 150 prescriptions in a day makes an error, both the pharmacist and the store will be held liable, and will face a possible license suspension or revocation.
"Our discipline actions are going up," said David Work, the board's executive director, "and errors are a part of that."
Computers are an important part of the pharmacy safety net, but they have limitations. When Chase typed in the name of a 23-year-old patient who had been prescribed an anti-psychotic medication, his computer issued a warning that the drug could be dangerous in combination with another prescription in the patient's file.
But the system presumes that a patient goes to the same pharmacy every time. And the computers raise so many red flags, without distinguishing the serious from the benign, that pharmacists grow weary of them and start to ignore them.
In the Rite Aid case in Washington, one pharmacist dispensed a drug with instructions for the patient to take triple the proper dose, an order that, state officials said, would have resulted in a computer alert. The message was apparently ignored.
"It's like crying wolf," said Susan Winckler, director of policy and legislation for the American Pharmaceutical Association, which represents 52,000 pharmacists. "Some pharmacists call it 'the right-hand syndrome.' You just hit the return key when you see the message."
Cohen, of the Institute for Safe Medication Practices, says most pharmacy computer systems need serious improvement. In a recent study, he asked 307 hospital pharmacies to fill 10 different drug orders that had killed patients in 1998. Some contained an overdose. Others called for two drugs that were deadly in combination.
"The results were outrageous," he said. Only four of the 307 pharmacies detected all 10 unsafe orders.
Deaths and injuries from drugs are vastly underreported, experts say, in part because doctors fear civil lawsuits or, worse, prosecution. When Miguel Sanchez died, the district attorney in Adams County, Colo., Bob Grant, brought charges of criminally negligent homicide against three nurses who cared for the baby. Two pleaded guilty in exchange for two years' probation; another was acquitted at trial.
"They failed to perceive a substantial risk that the death of a child would occur," Grant said. "That's criminal negligence."
Cohen, of the Institute for Safe Medical Practices, disagrees; after Miguel's death, he said, he uncovered 54 procedural shortcomings that contributed to the mistakes that killed the boy, from a hospital pharmacist who lacked training in how to properly dose drugs for infants, to unclear labeling on the syringe, to the textbooks that lacked crucial warnings. Had any of the shortcomings been corrected before Miguel's birth, he said, the boy might be alive today.
Ms. McCadden, the hospital's risk manager, acknowledged the flaws and said that, under Cohen's guidance, the hospital had taken a variety of steps: "Any medication going to the nursery is now checked by two pharmacists. Two nurses in the nursery will also double-check the medication."
The hospital also hired a pediatric pharmacist, ordered new textbooks and conducted educational sessions for its staff. And Ms. McCadden and the three nurses have told their story to other hospitals and at conferences in an effort to educate other professionals. "We've done a lot of talking," Ms. McCadden said.
The idea that the health care system can be designed to minimize mistakes and drug dangers is one that has been promoted heavily by Dr. Leape. "Errors," he says, "are symptoms of a sick system, not a sick person. Humans make mistakes. To the extent you can redesign around that, you can get rid of it."
For example, he said, the F.D.A. could require pharmaceutical companies to standardize their drug labels for easy reading. Medicines could come with bar codes, so that pharmacists could use scanners to check for the correct name, the same way a grocery clerk scans a jar of pickles. Doctors could trade in their prescription pads for computers.
These ideas are beginning to catch on in some unlikely places. Two years ago, Dr. Kizer, of the Veterans Administration, began a major patient safety initiative designed, in part, to minimize prescription drug errors at the nation's 172 veterans hospitals and clinics. Over the next two years, the department intends to spend $40 million on technology that will allow doctors to use computers to write their prescriptions.
At the Veterans Administration Medical Center in Providence, a stately brick building that looks anything but high technology, the results are already in evidence. Doctors still walk around with prescription pads in their laboratory coat pockets, but only out of habit. They have not used them since December except to prescribe narcotics.
A computer terminal is in every examining room. Wireless portable units (the hospital has installed optic fiber cables in the ceiling) are on rolling carts in the hospital corridors. When a doctor enters a prescription into the computer, it is checked and double-checked. The machine rejects spelling errors, or overdoses, and scans the patient's medical record for potentially dangerous interactions with drugs prescribed by other doctors. The computer then sends the order electronically to the pharmacy.
In an analysis of a similar system at the Brigham and Women's Hospital in Boston, Dr. Leape found that medication errors were reduced by 80 percent. But hospitals have been slow to get rid of prescription pads: according to Cohen, 12 percent of the nation's hospitals have the capability for computerized prescription writing, but only 6 percent use it.
That is partly because not all doctors are enthusiastic about the system. When Dr. Chirico-Post, the chief of staff at the Providence V.A. center, announced that her hospital would be among the first in the Veterans Health Administration to switch to computers, some doctors complained that they did not know how to type. Others said it would take too much time. And even those who like the system said it had its drawbacks.
Dr. Dawna Blake, chief of the hospital's primary-care practice, says she welcomes the warnings the system issues when she is writing a prescription. "It gives you a lot of nice reminders," she said.
But the machine does slow her down, she said. She still takes patient notes by hand and then enters them into the computer at the end of the day. "I can't sit there and enter my notes when the patient is in the room," she said. "To me, that's a distraction."
Those arguments did not deter Dr. Chirico-Post. With a hospital pharmacy filling more than 500,000 drug orders for inpatients each year, she said, and another 500,000 outpatient prescriptions, the potential for errors and dangerous interactions is too great to ignore.
"Outside of working in the operating room," she said, "dispensing a drug, giving a drug to the patient, is one of the most dangerous things we do."
New York Times June 3, 1999 http://www.nytimes.com/library/national/science/060399sci-prescriptions.html
OUR COMMENT: This is a fascinating article that helps explain why prescribed drugs are the number three killer in this country. Not only do we have to worry about the toxicity and danger of the drug itself, but we need to be extra cautious when we get prescriptions filled that it is in fact the correct drug. One simple step is to know your drug’s name if you use any prescription drugs. Know both the brand and generic name and make sure you ask the pharmacist if this is what your drug is as simple double check to make sure no mistake was made in filling your prescription. It is your responsibility to know what drug your doctor has put you on. This simple step could save your life.
The optimum solution? Don't get in such a bad shape that you need drugs!
Take this preliminary  to see if your condition could respond to treatment.
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