When your physician writes a prescription for you, be certain that you know the instructions for taking the drug. If necessary, write down the instructions the doctor gives you verbally for taking the drug(s). It could save your life.
Any doctor can make a mistake. A physician can become distracted and write the wrong instructions or write the prescription for the wrong medication. Mistakes can also be made when electronically transmitting prescriptions to the pharmacy. Sometimes, a pharmacy does not adequately check the instructions printed on medication packaging. The result, all too often, is serious or tragic.
You might recall the days when every pharmacy was staffed by several pharmacists and the medications were checked and packaged by one of the pharmacists. If something seemed wrong, the pharmacist would call the prescribing physician and the problem would be resolved. You knew your pharmacist and your pharmacist knew you and the conditions or illnesses for which the medication was prescribed.
Fast forward to 2017, and you will have difficulty finding an independent pharmacy that still operates this way. You are more likely to fill your prescriptions at the grocery store or at a large chain drug store. Chances are that there will be only one pharmacist working. Increasingly, pharmacists depend on pharmacy techs to actually fill the prescription, with the pharmacist only checking the prescription before it is delivered to you. These pharmacists are extremely busy. Sometimes, they make mistakes, as well.
If the doctor makes a mistake when writing the prescription or the pharmacy fails to check the instructions on the package, the compounded error can be deadly.
A few months ago, a tragedy occurred in Northern Virginia when such a compounded error caused the death of the patient. A male patient, aged 53 was being treated for a brain tumor. He had been diagnosed in 2005 with a glioblastoma. He was doing well with treatment, which was part of a NIH clinical trial. He was returned to the care of his oncologist. He was prescribed two medications. One of the medications was very toxic. It was intended to be taken once, at the beginning of the new course of treatment. The second drug was less toxic. It was to be taken daily for 13 days.
The prescribing physician reversed the instructions for taking the medications when transmitting them to the pharmacy. The pharmacy filled the prescription, without noticing the error, and delivered the medications to the patient. The patient took the two medications as instructed on the packages. He quickly became quite ill. By the time the dosing information error was noticed, it was too late to reverse the damage, and the patient died from taking the wrong (and toxic) chemotherapy drugs.
A lawsuit was filed by the patient’s wife and daughter. A claim was filed against the prescribing physician because the instructions were reversed. A claim was also filed against the pharmacy because it failed to notice the error before filling and delivering the medications with the wrong instructions. This tragic case was settled in mediation for $1,600,000.
Unfortunately, medical malpractice happens every day. Perhaps the work load and time constraints put upon the doctor and the pharmacy contributed to this compounded error. Yet, the fact remains that the patient died as a result. All medication errors are not so tragic. Any medication taken incorrectly can, however, cause serious harm.
What can you take away from this story? There is a warning and a possible method of prevention in this sad story. When your physician prescribes any new medication, be certain that you understand how to take the medicine and that you are aware of potential side effects. If you are concerned that you will forget any of this information, write it down, or ask your physician to write it down for you. You need to double-check prescription instructions.