Anonymous

"Oh that happens all the time" "We put something in the computer and it comes out different"
Anonymous
One mother soon discovered that her local pharmacy had committed two very serious errors and both those errors involved her toddler. Not only did this mother meet with indifference when she contacted the pharmacy, she also found that while there was a system in place to protect the consumer - that system failed because of indifference. A new loud and clear voice has been added to ours in demanding accountability in health care delivery.

This is what the mother learned.

• When a pharmacy error occurs, personnel in the pharmacy are supposed to file an incidence report with the Department of Consumer Protection. ( in her case, and I am sure in most, it was not)
• On every medication you receive there is supposed to be clearly printed a number for you to call if a prescription is inappropriately filled. (in this case, small print and hidden in plain sight)
• If a pharmacist commits two errors, he or she is supposed to lose his or her license. (in this case, the pharmacist was given a promotion)
• The Department of Public Health does not hear these cases. It comes under Consumer Protection in our Attorney General's Office

It looks like it is once again going to be up to the consumer to demand greater accountability. If you believe that you've been given the wrong medication by your pharmacist, please contact your physician and pharmacist immediately. If you confirm that your pharmacist has incorrectly filled your prescription, you may wish to report it to the Department of Consumer Protection Drug Control Unit at (860) 713-6065.

Thank you for bringing this to our attention. CTCPS has been keenly aware of the Institute of Medicine's June 2007 report that documented on average one medication error per day for each hospital patient. But insight into what happens in our pharmacies had not come to our attention. And now it has.

The person who brought this to our attention has some additional comments about what she feels is important for you to know.

"The incident report is required to be filed internally. I don't know if the pharmacy is required to pass along the incident report. It becomes an issue if a complaint is filed with Consumer Protection and no incident report is found to have been created. I don't know what, if any, consequence there would be if no report was found on a substantiated error. In fact I was told that I was very much the exception (in the order of 1% or so) that actually had the "evidence" to turn over to the state. Pharmacists generally tell the patient/victim to bring in the bottles so that they can check them. They then retain the bottles and the Drug Control Division is unable to pursue any sort of investigation so the investigation is closed or found to be "unsubstantiated." Errors therefore should immediately be reported to the physician and Drug Control. Patients who bring the errors to the pharmacy will probably be shut out of what little protection we have.

Also, from what I can tell it is very rare for a pharmacist to actually lose their license. Most enter a plea agreement of sorts that involves at most a fine and probation. The same agent who told me that they try to protect the privacy of pharmacists who may have developed substance abuse issues also said that once they have evidence of enough errors (although he wouldn't clarify what counted as "enough") they try to convince the pharmacist to voluntarily give up their license. He said a almost all pharmacists concede the error because then they remain anonymous. It is exceedingly rare for a pharmacist to subject themselves to a hearing that would cost them their license against their will.

Also, I think that it is important that people know that no information about pharmacy errors is available to the public. The victim is not allowed to make a statement to the pharmacy board or even review the "statement" prepared by the investigating agent on their behalf. Unless the pharmacist is foolish enough to demand a hearing their name or location is NEVER made available. There is therefore no way to choose a "safe" pharmacy over a "dangerous" one. This is in stark contrast to other businesses that Consumer Affairs oversees. You can make an informed decision prior to hiring a home improvement contractor but NOT filling a life or death prescription for your child."