Preventing a prescription mix-up - KAIT-Jonesboro, AR-News, weather, sports


Preventing an Rx mix-up

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An estimated four out of five adults in the United States take prescription drugs, over-the-counter medications, or dietary supplements.

That's a lot of pills Americans are ingesting daily and that means there is no room for error.

But these mistakes do happen.

Recently, a New Jersey pharmacy made headlines for mistakenly distributing breast cancer drugs instead of fluoride pills to children.

Giving a prescription drug to the wrong person is the ultimate pharmacy failure.

"Pharmacists and technicians work diligently to make sure that doesn't happen, but errors do occur," says Michael Manolakis, assistant dean at Wingate University School of Pharmacy.

In about 12 percent of cases, according to a study published by the Journal of the America Medical Informatics Association, of the almost 4,000 computer-generated prescriptions received by a chain of commercial pharmacies, nearly a third of the 466 total errors were considered potentially harmful.

America Now wanted to know what pharmacists do to keep their own families safe from these type of errors.

The first thing to remember is that prescription drug safety starts at your doctor's office.

When your physician is writing your prescription, ask them about the name of the drug, how the prescription works, its strength, as well as how long you should take the drug and how to store the medication. You should also ask about any possible side effects.

"As your physician is giving you answers, take your smart phone out and jot down the note," recommends Manolakis.

When you arrive at your pharmacy, take advantage of the opportunity to ask them the same questions.

"The technician will say as they process the prescription, 'Would you like to ask the pharmacist a question?' And at this point, you say -- 'Yes I do! I have a couple of questions,'" Manolakis adds.

Take out your notepad or your phone, and check to see if the pharmacy technician's answers correlate with the information provided by your physician.

"If they [customers] feel like their pharmacy is too busy to answer these questions, then they should consider going to another pharmacy that does have the time to answer these questions, because it is about their health," points out Joe Moose, the pharmacist manager at Moose Pharmacy in Concord, North Carolina. 

Pharmaceutical mix-ups can also happen in the maze of our medicine cabinets and drawers at home with faded labels, unmarked packages and similar-looking pills.

Before acting as your own personal apothecary, let the professionals take a closer look at your medicines. 

Pharmacists can read a pill and easily identify it by color, shape, size and little marks like numbers and letters.

You can look your medications up online, but it is much better to bring your pills back to your pharmacy or call them to make a match.

This is also important to remember when getting a refill, even when taking the drug is routine.

Don't forget to do a double-take to ensure the accuracy of the pills you have been given.

"The manufacturers can change the color of the medication or the pharmacy can switch manufacturers and still be dispensing the same medication, but if it looks different, you do want to ensure that was the medication intended for you," Moose points out.

Medication and those white coats can be a little intimidating, but taking a few minutes to ask a few questions gives you, your family, and your pharmacist a chance to check.

It's a simple dose of precaution, that can often prevent any damaging side effects of a prescription slip up.

Additional Information:  

  • A CVS pharmacy in Chatham, NJ, mistakenly distributed a breast cancer drug (Tamoxifen) to children instead of fluoride pills. As many as 50 families were affected between December 1, 2011, and February 20, 2012. Click to read more.

The following information is from a Wall Street Journal article entitled "Catching Deadly Drug Mistakes."

  • Medication errors cause at least one death every day and injure approximately 1.3 million people annually in the United States, according to the Food and Drug Administration.
  • The non-profit Institute for Safe Medication Practices and the American Society of Health-System Pharmacists are launching a new National Alert Network for Serious Medication Errors. The network will be used to send email alerts to 35,000 pharmacists working in hospitals and health systems, as well as physicians and nurses, when a dangerous or life-threatening error is reported.
  • Growing pressure on hospitals to cut costs and stretch staff in a tough economy may be fueling an increase in medication mistakes. In a survey ISM, of 850 respondents-predominantly nurses and pharmacists working at staff or managerial positions in hospitals-nearly half reported a large or moderate negative impact on medication safety in their hospitals due to the economy, with 20% reporting mistakes in the past year with the most dangerous medications such as insulin, narcotics, heparin and chemotherapy.
  • The culprits include illegible handwriting on a doctor's prescription, poorly communicated orders and drugs with names that sound alike or have similar labels for different dosages.
  • The drawing on prescription drug packages should show the shape of the pill, the color and any markings. (Source: She Knows parenting website, CVS prescription mix-up a reminder to check meds)
  • Similar labeling, similar names, under trained technicians, abbreviations on written prescriptions may be to blame for pharmacy mistakes. (Source:, See How Drugs Get Mixed Up at Pharmacies)
  • Click here for a "pill identifier" website:
  • According to one estimate, in any given week four out of every five US adults will use prescription medications, OTCs or dietary supplements of some sort and nearly one third of adults will take five or more different medications. (Source: Institute of Medicine of the National Academies,

The following information is from a U.S. News & World Report article entitled "E-Prescribing Doesn't Slash Errors, Study Finds" and based on information obtained from a study published in the Journal of the American Medical Infomatics Association. 

  • Researchers examined 3,850 computer-generated prescriptions received by a commercial pharmacy chain in three different US states over a 4-week period in 2008. Of those, 452 (about 12%) contained a total of 466 errors, of which about one-third were deemed to be potentially harmful.
  • Of the 163 potentially harmful errors, 58% were considered "significant" (diarrhea, rash, headache, etc) and 42% were "serious" (low blood sugar, reduced heart rate, fainting). None were considered life-threatening.
  • Nervous system drugs, cardiovascular drugs and anti-inflammatories/antibiotics were the most common types of drugs involved in errors.
  • More than 326 e-prescriptions were written in 2010, up 72% from 2009. (Source:
  • 48% of people use at least one prescription drug in the past month (Source:
  • Mix ups can occur when there is a miscommunication of symptoms from patient to doctor, the doctor does not understand the symptoms, or there is an error in the electronic message. (Source: Joe Moose, pharmacist manager at Moose Pharmacy in Concord, NC.)
Copyright 2012 America Now. All rights reserved.
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