I-TEAM: PRESCRIPTION DRUG DISPENSING ERRORS KILLS 100,000 IN U.S.

The CBS 11 I-Team has learned that there are more than 2.3 million prescription drug
dispensing errors made in pharmacies across the United States.

The statistic is staggering. About 100,000 patients die every year because of this problem.

PHARMACY DISPENSING ERRORS

Lake Towakoni resident Linda Lilley thought she was taking her pain medication
Gabapentin, but she says her bottle had a different medication, which looked very similar to
Gabapentin. But it was in fact Gemfibrizol- a cholesterol drug, she didn’t need.

The bottle had a correct manufacturer label but she says the pharmacist put the wrong label
on it.

((SHOW BOTTLE PICTURE))

It sickened her to the point that she couldn’t even move. She needed help doing day to day
chores. “I felt nauseated,” she told CBS 11 news.
“By the third day, I was debilitated,” she said.

The pills looked so similar that Linda didn’t suspect anything was wrong. Finally, when she
found out the mistake one morning while looking at the bottle closely, she thought she had
an answer. A google search of the medication confirmed her doubts. She immediately stop
taking the medication. But by that time, she had taken the wrong drug for 12 days, 3 times a
day.

EFFECTS OF MEDICATION MISTAKES

Since 2016, about 200 pharmacists have been disciplined for making errors in Texas. Many
go un-reported. The documents obtained by the I-Team show some striking examples of
dispensing mistakes.

A wrong dose of medication sent a 3- month old to ICU for 5 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’S GOING ON?

The similarity in names is one of the big causes for confusion, experts told the I-Team

Dr. Marv Shepard, former dean of pharmacy at University of Texas in Austin says sometimes
the errors occur because pharmacists are overworked.
“They're having trouble because of the pressures of the environment,” he told investigator
Ginger Allen. The stress of staying open 24 hours sometimes gets to them.

He said pharmacists stock on an average of 5000 drugs

Dispense 300 prescriptions daily and make 2-4 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 caught in dispensing errors are insulin and anti-
coagulants. And most of these occur in just about every well-known pharmacy you can think
of. The I-Team reached out to some of the pharmacies listed in disciplinary actions by the
State of Texas. ((see statements of pharmacies here – CVS, Walgreens, Brookshire, Kroger,
HEB, Tom Thumb))

He says often times the errors are not reported.

MANUFACTURER’S MISTAKE

The I-Team has learned while rare, sometimes the drug manufacturers have also known to
put in a wrong medicine in a sealed bottle and then sent them to the pharmacies.
That’s exactly what happened to Carin Bollinger.

For 30 days, Bollinger, a resident of Dallas thought she was taking Clipidogrel- 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.”

She eventually received this 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 manufacturer, International Labs did not want to comment on the case.
https://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalPro
ducts/ucm592047.htm
((See 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. Bar code technology has
also helped lower dispensing errors.

See bad handwriting samples here ( I have a pdf, you can pull samples from there)

Both Bollinger and Lilley say the one thing they have learned in this experience is that they
don’t trust everything they take anymore. “We all need to be aware of it. Look at your
medications,” Lilley said. That’s 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 tear off the insert, make sure to check the description of the drug to what is in
the bottle. Online sites can also help you determine what your pill should look like and if
you have the right pill. Website links
https://www.webmd.com/pill-identification/default.htm
https://www.drugs.com/imprints.php
https://www.cvs.com/drug/pill-identifier
https://reference.medscape.com/pill-identifier

Here are some ways you can avoid taking the wrong medication

http://www.consumermedsafety.org/tools-and-resources/medication-safety-tools-and-
resources/taking-your-medicine-safely/general-advice-on-safe-medication-use

https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm096403.htm