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Medication Mistakes: They can be a matter of life or death

A recent study found nearly 1.5 million medication errors occur each year. That’s roughly one every 21 seconds.

By: Sandra Jones

Originally Published: January 25, 2021

(InvestigateTV) – Al Carter regrets the day he gave the wrong medication to a 12-year-old.

“At first, I was in shocked.” Carter said. “Immediately, after it was dispensed, I caught it.”

Fifteen years ago, Carter was working at a local pharmacy in Biloxi, Mississippi and faced a difficult task of calling the family.

“I completely and profusely apologized for the error,” Carter said.

The family returned to the pharmacy, got the right antibiotic medication, and the situation turned out okay.

“It was one of those things where it was myself and another pharmacy technician in there with two prescriptions, two different patients sitting right there, and I knew they were waiting. And I grabbed the wrong one to give to the patient,” Carter said.

The pharmacist is now the executive director and CEO of the National Association of Boards of Pharmacy. He explained that similar packaging and names of prescriptions are the most common cause of medication mistakes. For example: accupril and aciphex may look similar.

“I think it’s truly an oversight,” Carter added.

InvestigateTV found numerous studies that reveal how major medication errors have caused serious problems for patients.

A 2017 study published in Clinical Toxicology stated that there were nearly 1.5 million medication errors each year in U.S. That’s roughly one every 21 seconds.

The researchers looked at calls to poison control centers and discovered most of the mistakes included taking the wrong medicine, the wrong dosage or accidentally taking a medication twice.

Heart medication mistakes accounted for more than a fifth of errors, according to the study.

It also reported that medication errors doubled between 2000 and 2012.

When asked if the fault belonged to prescribers or pharmacists, Carter assigned blame to both.

“Part of prescription errors is to be human,” he said. “I think all pharmacists and all individuals make errors.”

Amanda Payne Lindsay said she was prescribed a different hormone combination than she said she should have and was experiencing several symptoms from the increased hormone levels. She showed InvestigateTV an email from the insurance company for the hospital where she had her prescription filled, which acknowledged there had been a mistake.

Patients such as Amanda Payne Lindsay, 36, never imagined it would happen to her.

“My life was terrible. I was suffering,” Payne Lindsay said.

For four months, she said she went back and forth to different doctors trying to diagnose her symptoms.

“I felt like I had heightened depression, heightened anxiety,” she said. “I was coming home crying every night…not know what was happening.”

She discovered that the medication the primary care physician prescribed for her was the wrong one.

Payne Lindsay said that she was supposed to get a specific birth control called Yaz.

Instead, she was given Femhrt – also known as Ethinyl Estradiol and Norethindrone – which is used as hormone replacement therapy in a lower dosage and contraception in higher doses.

“I didn’t think twice about the packaging,” Payne Lindsay said. “I didn’t think twice about checking the name of what I was taking because my physician prescribed it, the pharmacist acknowledged what it was.”

Payne Lindsay said it was her OBGYN doctor who alerted about the HRT medication during an appointment.

“She said, ‘Why are you on Hormone Replacement?’ And I looked at her and I said, ‘I’m not.’ And she said, ‘Yes, you are.’ And I said back to her, ‘No, I’m not.’”

Payne Lindsay said after stopping that medication, it took several months before she began to feel better.

“I was like, oh life is not so hard and baffling,” Payne Lindsay said.

Ironically, she’s a hospital chaplain and mentioned that she picked up the prescription from the pharmacy inside of the Illinois hospital in which she worked.

Payne Lindsay filed a claim against the hospital and received an emailed response back from the hospital’s insurance company which confirmed the mistake.

“I had no reason to really question that it was even wrong, especially within the hospital system that owns the pharmacy. So, you’re thinking communication is real tip top here,” Payne Lindsay said.

Carter told InvestigateTV that his organization has recommended that a task force work with state pharmacy boards nationwide to evaluate the working conditions of its pharmacists and the causes of medication mistakes.

“Our boards aren’t necessarily going after them in a disciplinary standpoint, but more of a just cause. So, that they educate them on different things or different trends that they’re seeing,” Carter said.

Currently, the state pharmacy boards in Arkansas, Oklahoma, and South Dakota voluntarily document mistakes and determined causes to help their board inspectors address workload issues and prescription errors.

The conversion to electronic medical records is credited with helping to prevent medication mishaps.

Dr. Danielle Ofri is the attending physician at New York’s Bellevue hospital and clinical professor of medicine at NYU Grossman School of Medicine. She has written books on medical mistakes.

While electronic medical records might seem to be another layer of protection, she called them a double-edged sword.

“On the one hand, the electronic medical record – EMRs has eliminated the hand-writing problem, which was a huge problem,” Ofri said. “But it has brought about its own problems.”

Sometimes, medications aren’t removed even though the patient no longer is taking them, she said.

“So, we have that problem. Duplicate medications that happen,” Ofri added.

She also said that electronic medical records could become a liability based on the number of alerts doctors have received about every medication prescribed for the patient.

The automated alerts notify physicians when patients are at risk of death.

“For example, I had a patient who was 65 and I got a warning about lactation. I’m thinking the chance of my 65-year-old patient getting pregnant and breastfeeding is very small,” Ofri said. “We’re being flooded by a forest of maybe not less important things, and we’re missing the important ones which wouldn’t happen with the paper chart.”

Experts say that patients need to practice diligence when prescribed a new medication. The Mayo Clinic has these tips to prevent errors:

  • Know your medications and the possible side effects.
  • Ask questions or share concerns with your doctor.
  • Keep an updated list of all your medications.
  • Save the information sheets that come with your medications.
  • Use the same pharmacy for all of your medications.
  • And when your pick-up a prescription, make sure it’s the one your doctor ordered.

It’s something that Amanda Payne Lindsay will keep in mind for the future.

“I will always double check and triple check what my medications are,” Payne Lindsay said. “It could’ve ended up very bad.”

She is currently waiting for a response to the claim she filed against the Illinois hospital where she received the wrong prescription.
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