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Prescription Drug Dispensing Errors Kill 100,000 People Per Year In US

DALLAS ( KTVT ) – The investigative team at KTVT-TV has learned there are more than 2.3 million prescription drug dispensing errors made every year in pharmacies across the United States.
About 100,000 patients die every year because of a pharmaceutical mistake according to reports published by the National Center for Biotechnology Information.
PHARMACY DISPENSING ERRORS
Lake Towakoni resident Linda Lilley thought she was taking her pain medication Gabapentin, but she says her bottle contained Gemfibrozil- a cholesterol medication which looked very similar to Gabapentin.
The bottle had a correct manufacturer label but she says the pharmacist put the wrong label on it.

She got so sick she says she eventually could not move. She needed help doing day-to-day chores.
“I felt nauseated,” she said. “By the third day, I was debilitated.”
The pills looked so similar that Lilley did not suspect anything was wrong. Finally, one morning, she looked at the bottle closely and discovered the mistake. She immediately stopped taking the medication; however, by that time, she had taken the wrong drug for 12 days, three times a day.
EFFECTS OF MEDICATION MISTAKES
Since 2016, KTVT learned the State of Texas has disciplined nearly 200 pharmacists for making errors. The documents obtained by KTVT show some striking examples of dispensing mistakes.
A wrong dose of medication sent a 3-month-old to ICU for five days. The infant was given 100 times the prescribed amount.
Another example indicated a wrong strength of a drug rushed a 7-year-old to the ER with heart problems.
A wrong drug left another patient with an increased risk of cancer.
A patient was prescribed “cyclosporine” but instead, the pharmacist filled “Cyclophosphamide.”
WHAT IS GOING ON?
The similarity in names is one of the biggest causes for confusion, experts told KTVT.
Dr. Marv Shepard, the former Chairman of the Pharmacy Administration Division of the College of Pharmacy at the University of Texas in Austin, says errors typically occur because pharmacists are overworked.
“They’re having trouble because of the pressures of the environment,” he told KTVT. Dr. Shepherd says the stress of staying open 24 hours can be overwhelming.
He says the typical pharmacy stocks up to 5,000 drugs, dispenses 300 prescriptions daily and makes two to four mistakes every day.
Dr. Shepard believes it results in about 100,000 deaths in the U.S. “It’s huge, it’s a big problem,” he added.
He says the two most common drugs involved in dispensing errors are insulin and anti-coagulants. And most of these occur in just about every well-known pharmacy you can think of. KTVT reached out to some of the pharmacies listed in disciplinary actions by the State of Texas.
CVS PHARMACY STATEMENT
The health and well-being of our patients is our number one priority and we have comprehensive policies and procedures in place to ensure prescription safety.  We regularly seek out new technology and innovations to improve our systems, we engage with industry experts for independent evaluations of our dispensing procedures, and we are committed to continually improving our processes to help ensure that prescriptions are dispensed safely and accurately.  Prescription errors are a very rare occurrence, but if one does happen, we do everything we can to learn from it in order to continuously improve quality and patient safety.  
WALGREENS PHARMACY STATEMENT
The quality and safety of our pharmacy services is the top priority for Walgreens, and we take any prescription error very seriously. That’s one reason we have a multi-step prescription filling process with numerous safety checks in the process to minimize the chance of human error. We also encourage patients to check with our pharmacists or their health care providers if they have a question or concern about their medications. Together, we can help ensure our patients get the best care.
WALMART STATEMENT
We work hard every day to ensure we live up to the high standards we set for ourselves and that our customers expect. We have quality control measures in place to help ensure that any medications we provide our customers are the medications prescribed.
Despite the stacks of disciplinary actions KTVT received from the state, Dr. Shepherd says most errors are never reported.
MANUFACTURER’S MISTAKE
KTVT learned it is not just pharmacies making mistakes. While it is rare, drug manufacturers have also put the wrong medicine in a sealed bottle and then sent the bottle to pharmacies.
That is exactly what happened to Karin Bollinger.
For 30 days, Bollinger, a Dallas resident, thought she was taking Clopidogrel, her prescribed blood thinner. But instead, the bottle contained Simvastatin, a cholesterol drug. She too suffered serious side effects.
”I had lost about 17 pounds in 12 days,” she said. “I had a horrible rash, blisters, and ulcerations across my chest.”
Bollinger eventually received a recall letter from the maker warning her about the mix-up in the manufacturing process, but that was months later.
“The drug mistake had been made,” Bollinger said.
The KTVT asked the manufacturer, International Labs, to respond to the error but it did not want to comment on the case.
READ FDA RECALL LETTER HERE
WHAT IS BEING DONE
Experts say the industry is cracking down on errors at the manufacturer and pharmacy level. The FDA has created a commission to change the names of similar sounding drugs. Electronic prescriptions have helped with handwriting mishaps. In addition, barcode technology has also helped lower dispensing errors.

bad handwriting prescription

Both Bollinger and Lilley say their experiences have taught them to always double check their prescriptions.
“We all need to be aware of it. Look at your medications,” Lilley said. That is the only way to stay safe she added.
“This has taught me to check every one of my medications,” Bollinger said.
WHAT CAN YOU DO?
When you leave the pharmacy and tear the insert off of the bag containing your medicine, make sure you check the description of the drug on the insert and compare it to what is in the bottle.
Online sites can also help you determine what your medicine should look like and if you have the right pill:
WebMD’s Pill Identifier
CVS Pill Identifier
Medscape Pill Identifier
Here are some more ways you can avoid taking the wrong medication.
[H/T CBS DFW ]

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