Pharmacy Error: A Silent (But Dangerous) Epidemic

Tonight’s 20/20 program (see “Tragic Mistakes”) sheds light on what can only be called a silent epidemic of the occurrence of pharmacy errors across the nation. The segment featured the tragic story of a young mother who gave her four-month old daughter who was born prematurely what she thought was an anti-seizure medication. What she actually gave the infant was an adult dose of a diabetes medication, which left her daughter permanently disabled, unable to talk, walk or feed herself. Walgreen’s, the national pharmacy chain, was responsible for the dispensing error, this act of negligence that caused irreparable harm.

This is not a new phenomenon. It happens more than you think. In an article published on in the summer of 2006, it was reported that each year, as many as 1.5 million Americans suffer illness, injury or death because of mistakes made in prescribing, dispensing and taking prescription drugs. And it has been estimated in a report published in 1999 by the Institute of Medicine of the National Academies that more than 7,000 people in the U.S. die annually from medication errors.

The problem is that when pharmacy errors happen, the national chains most often times strong arm the victims into signing confidentiality agreements so the public never knows the extent of the problem that is pharmacists’ negligence. And, in 46 states across the nation, there is no requirement for drug stores to report pharmacy errors.

Pharmacy negligence is on the rise, especially among the nationally recognized chains, because the pharmacists working there are overworked, often pulling twelve hour shifts, and this pressure is leading to fatal mistakes. This is a classic example of how corporate profits, the need to boost them at all costs, trumps the public interest.

Even if pharmacy errors are reported to the pharmacy board of a given state, most states have enacted legislation protecting the data, treating it as privileged and confidential; therefore, not subject to discovery, use or subpoena, or admissible as evidence in any administrative, disciplinary, civil or other proceeding, except for internal review purposes. So essentially pharmacies across the nation get the green light to police themselves, a task at which they are failing, and no one else gets to know about it.

The intent of these protective laws is to encourage the reporting of such errors by the pharmacists themselves so that the industry can learn from these mistakes, thus reducing the incidence of misfills. While that may be a good objective, on the flip side, it also serves to completely insulate the public from vital information they need in order to protect themselves from egregious or repeat offenders. We need to strike some level of balance, to encourage safer practices, to encourage the reporting of incidence, and to keep the public informed and safe.

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