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Common Medication Errors of Pharmacy Technicians

Common Medication Errors of Pharmacy Technicians


colorful-pills-01Medication can save lives, but they do so only when they’re taken correctly – by the right patient, who takes the right medicine, at the right time, in the right dosage, by the right route, and for the right amount of time. The responsibility of all of this falls upon the pharmacy technician.

According to the National Patient Safety Foundation, of the 3 billion prescriptions that are filled, as many as 30 million dispensing errors occur. While some of them are not even noticed, others can have serious consequences, even resulting in death at times. The most common pharmacy errors occur when:

• Pharmacy technicians hand out the wrong prescriptions to patients – they get the names wrong, which means the entire set of medicines is wrong. (Pat was once given pills for another patient with the same last name. The technician did not ask for her first name.) And when patients fail to check the drugs they’ve been given and follow the prescription blindly without even looking at the name, it spells disaster in the making.
• Overworked and negligent pharmacy technicians give out the wrong drug because they don’t read the prescription carefully. This could cause serious consequences if the patient is allergic to the new drug or if it worsens their symptoms and causes them to become more ill.
• Pharmacists and technicians substitute one drug for another without checking with the doctor who prescribed the drug. This could lead to complications because the pharmacist is assuming that he/she is qualified to make the switch.
• They give out drugs that are past their expiration dates and which could either cause harm or not effect a cure since they are worthless past a certain date.
• Pat adds: They can misinterpret handwriting and fill the prescription with the wrong medication.

Errors can have profound consequences for the pharmacists who supervise technicians.

A former Ohio pharmacist pled no contest to involuntary manslaughter of a 2-year-old child who died in 2006 as a result of a chemotherapy compounding error. The pharmacy board revoked the pharmacist’s license, and a grand jury indicted him on charges of reckless homicide and involuntary manslaughter. The pharmacist faced up to 5 years in prison. Prosecutors held the pharmacist responsible for the toddler’s death because he oversaw the preparation of her chemotherapy. The child had undergone surgeries and four rounds of chemotherapy to treat a curable malignant tumor at the base of her spine. She was supposed to receive her last dose of chemotherapy on the day of the error. A pharmacy technician mistakenly prepared the infusion using too much 23.4% sodium chloride.

According to a news report, the technician mentioned to the pharmacist that the final preparation didn’t seem right, but the error went unnoticed. The infusion was administered to the child, who died 3 days later.

The Institute for Safe Medication Practices expressed the outrage of many in the patient safety world that this case resulted in criminal charges.

Safety experts including ISMP advocate for a fair and just path for individuals involved in adverse events, arguing that punishment simply because the patient was harmed does not serve the public interest. Its potential impact on patient safety is enormous, sending the wrong message to healthcare professionals about the importance of reporting and analyzing errors.

Most of these errors occur when pharmacy technicians and pharmacists are too busy, distracted, and overworked. As patients, we can help minimize pharmacy errors by being vigilant, checking the name on the prescription, double checking the medicines against the prescription, ensuring that the drugs are not past their expiration date, and consulting the doctor before we switch to generic or branded equivalents.

Don’t be in a rush because it could be a matter of life and death – take the time to check with your pharmacist if you’re not sure that you’ve been given the right medication or if it looks different from what you’ve been taking so far. You can also check a quick reference list of medications to be on the safe side.

It’s your health and your life, and unless you assume responsibility for both, you are equal to blame for the disasters that happen when pharmacy errors occur.

This article is contributed by Ashley M. Jones, who regularly writes on the subject of Pharmacy Technician Certification.

See also Reducing Distractions is Reducing Medication Errors

Med League provides medical expert witnesses to trial lawyers. Please call us at (908)788-8227 or contact us today to discuss your next case.

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