The People's Perspective on Medicine

Is Frenzy in the Pharmacy Putting Patients at Risk?

Has the soul of pharmacy been sold? Are understaffing and time pressure in the pharmacy putting patients at risk of mistakes? How can you protect yourself?
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I grew up in small town America. New Hope, PA, had about 1,000 people in the 1950s. Even though it was tiny, New Hope had a big reputation. Nestled along the banks of the Delaware River, it was considered an artists’ colony. The author James Michener told people’s fortunes at the annual firemans’ fund-raising carnival. Tony Award-winner Oscar Hammerstein was famous for his songs in “The Sound of Music” and “Oklahoma.” Jan and Stan Berenstain lived close to where I went to elementary school in Solebury, PA. They authored The Berenstain Bears children’s book series (260 million copies in print).

The Independent Pharmacy: A Disappearing Resource

Less famous, but far more crucial to the health of our community, was Benny Sidon, R.Ph. Benny owned the local pharmacy at the corner of Main and Bridge Street. He was considered the accessible health authority, always ready with advice and cures for common ailments.

He sold all the usual OTC meds, filled prescriptions for all the local physicians and even compounded a fair number of old-fashioned remedies. Benny was never in a hurry. He took his time, talked to every customer and kept track of family comings and goings. His wife ran the cash register. It was literally a mom and pop operation.

What Happened to the Soul of Pharmacy?

There was no question that Benny, like most pharmacists in America, was highly regarded by his customers. For decades, pharmacists were the most respected professionals in America, above physicians, nurses and clergymen. They are still trusted, but they have fallen from the top spot.

Back then, most pharmacies were “independent.” That means they were owned by the pharmacists who ran them. Usually, the pharmacists lived in the community and knew their customers well. When they filled prescriptions, they took their time. Like Benny, they enjoyed talking with customers about their families and their health.

When we moved to Durham, NC, in 1975, Ninth Street was the hub of activity. John McDonald, R.Ph., owned a mom and pop pharmacy (McDonald’s Drugstore on Ninth Street). His wife Frances worked the cash register and helped make the best milk shakes in town.

John was renowned for the number of babies he was purportedly responsible for. Not in any inappropriate way! John had a concoction he would make up when a pregnant woman was past her due date. One wall had the photographs of dozens, if not hundreds, of baby pictures. The prompt delivery of these children was attributed to Mr. McDonald’s special drink.

Here’s how John described his relationship with the people of Durham: 

“I enjoy the community and the contact with the people,” he says. “I probably knew 90 percent of the customers, the families, and watched them grow up. Now we get a lot of people in just to look and reminisce.”

Modern Day Pharmacies:

The days when pharmacists like John Mcdonald and Benny Sidon were a cherished part of the community are pretty much gone. Today, most prescriptions are filled in chain pharmacies, groceries or big box discount stores. Most of your interaction is with the clerk or the technician rather than the pharmacist.

Is the Modern-Day Chain Pharmacy Putting Patients At Risk?

Just a few big chains dominate the market. As the companies have grown, they have applied cost-cutting measures, especially performance metrics, to their pharmacist employees. According to an article in The New York Times (Jan. 31, 2020)“How Chaos at Chain Pharmacies Is Putting Patients at Risk,” the pressure on pharmacists to fill lots of prescriptions quickly means that patient safety may be compromised.

A Fast-Food Model of Pharmacy?

One pharmacist has likened the work environment of a modern-day chain pharmacy to McDonald’s (food chain). That’s because speed is paramount in many of today’s chain store pharmacies.

This retired professional notes that

“The main difference is that a mistake in the pharmacy can be infinitely more serious than a clerk’s error in filling an order at a fast food outlet.”

We were dismayed to see that most pharmacy chains now have a drive-through window. This may seem convenient, but Benny would have been horrified to see what has happened to his profession.

A pharmacist described this development:

“Drive thru windows give the public the impression that filling prescriptions is no different than filling hamburger orders at a fast food restaurant.”

Pharmacy Mistakes Can Be Disastrous:

Pharmacy errors can be dangerous if not deadly. In one instance, a pharmacist dispensed the diabetes drug glipizide instead of the gout medicine allopurinol. The patient who took the mistaken medicine ended up with kidney failure and a stroke, which eventually killed him.

In another case, a 19-year-old pharmacy technician filled a prescription for the anticoagulant warfarin with 10 times the prescribed dose. The patient, a 46-year-old mother of three, suffered bleeding in her brain and ultimately died.

Are Errors in the Pharmacy Putting Patients at Risk?

Pharmacists undergo extensive and expensive education. Techs, on the other hand, may get much of their training on the job. A busy pharmacist in an understaffed pharmacy may not be able to monitor every prescription as carefully as possible.

How many errors actually occur in pharmacies each year? Surprisingly, there is relatively little research regarding this question. A study in 2009 found that one in five prescriptions dispensed deviated from the physicians’ written orders (Journal of the American Pharmacists Association, March-April, 2009).  Understaffing could lead to millions of errors a year.

Protecting Yourself in the Pharmacy:

How can you protect yourself at the pharmacy? First, talk to the pharmacist. The clerk or pharmacy tech will ask you to sign a waiver that allows you to grab and go. Don’t do it! Especially if you have not taken the medicine before, ask the pharmacist to verify that you have the correct medicine at the right dose and find out how it should be taken.

Never leave the pharmacy without checking that the pills in your bottle are the ones your doctor prescribed. Ask the pharmacist to check for drug interactions, including any with over-the-counter drugs, herbs or dietary supplements you may be taking.

Stories From Readers:

Sue shared a story about a close call that could have seriously impacted her daughter:

“My 11-year-old daughter takes Intuniv for ADHD. When I picked up her prescription, I was given Invega instead. Invega is an atypical antipsychotic drug. It is used for the treatment of schizoaffective disorder.

“Luckily, I noticed the mistake before I even left the pharmacy. When I asked the tech she said someone must have made a mistake entering it into the computer, I’ll just re-do it and give you the correct medicine.

“What I don’t understand is why they didn’t see in my daughter’s history that she takes Intuniv. I was told there are many checks before a medicine is handed to a customer. Then how did I get handed this incorrect medicine? I worry about what could it have done to my 75 lb. daughter?

“It is very scary. I switched pharmacies and check every pill that comes into my house.”

C.B.L. experienced a bizarre series of coincidences that led to a mistake:

“One time my family physician called in a new prescription for me. When I picked up the package, I noticed that the doctor’s name was wrong, but “my” name was correct. At first, I decided to ignore the mistake, but changed my mind, waited in line, and asked the pharmacist to check.

“Long story short, the prescription was meant for another woman who had the same first and last names. Her middle initial was “A”; mine is “B”. Her birth date was exactly one month before mine. Three close coincidences! It’s important to realize that weird mistakes CAN happen, and that we should double-check all prescriptions.”

Judy and her son’s close call:

“Years ago my epileptic son picked up his anti-seizure medication from the local chain pharmacy. Being a young man, he never checked the label or pill and started taking as prescribed. … 3 x day.

“He came over three days later not feeling well at all. He had been given, through pharmacy error, a strong diuretic instead of his prescribed medication. I checked the People’s Pharmacy paperback I had at the time and found the error. I immediately called the pharmacy and gave them a piece of my mind as my son was severely dehydrated and his electrolyte levels were out of range. A visit to his doctor resolved the dehydration and electrolyte imbalances.

“The regional manager of the drug store chain did call and offer my son a year’s worth of his medication to make to make up for the error. Me? I would have called a lawyer. Now I always check my pills by shapes, number and color whenever my refill contents change and for new scripts.”

You can learn more about the problems in pharmacies from the book, Chain Drugstores Are Dangerous, by Dennis Miller, RPh.

Share your own story in the comment section below. We have listed the “Top 10 Pharmacist Screwups” in our book, Top Screwups. Once you know what to look out for you may be better able to prevent pharmacy errors from harming a loved one.

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About the Author
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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When my daughter was very young and taking antibiotics for ear infections, a pharmacist caught the doctor’s error for dosage. The pharmacist recognized it was for a toddler and knew it was too much medication. They would not fill and release the prescription until they spoke with the doctor’s office. Needless to say I was very loyal to that pharmacy after that happened.

Thank you for reminding people to check their name as well as the pills themselves and to be familiar with what they are getting. This is not just a new happening due to frenzy.

About 25 or so years ago my Dr. gave me a sample of Bextra (which was subsequently taken off the market). A few days later I picked up a prescription at a local chain which our vet had prescribed for our aging cat. The name was correct on the bottle but when I looked at the pills I realized they looked just like my samples and, indeed, they gave her Bextra. I called the pharmacy, and the tech said she had probably mixed up the two prescriptions she had prepared. When I returned to the pharmacy my main interest was for them to find the patient they had given the wrong bottle to so that they weren’t taking pills meant for my cat. Sadly, they blew me off with a quick apology and didn’t seem interested in doing so. I got the impression they wanted to protect themselves from anyone else finding out about the error.

We have switched to mail order because of issues. Are they any better?

I worked in a grocery store pharmacy for a day some years ago. I was horrified at the pressure to fill and dispense prescriptions at what I considered a dangerous speed. I told management what I thought, but I doubt it made any difference. It’s a wonder more people aren’t harmed by incorrect meds, and I’m sure it’s worse now than it was then.

I use an expensive drug called Dofetilide 250 mcg # 60 which is a month’s supply and costs $ 160.00.

But twice, at the same big chain pharmacy in Florida and North Carolina, the bottle contained:
1) A different doctor’s name.
2) The pills were 125 mcg, which meant I will run out in 2 weeks, and I will pay another $160.00 for a total of $320.00 for a month’s supply.

I always check my bottle before I leave the pharmacy. This time the pharmacist just said: “Oh, somebody filled the wrong dose” without an apology.

After I got home from picking up my 90-year old Mother’s prescription at a national drug store chain, l noticed that the bottle was for another woman who had the same last name as my mother and her first name began with an “M” just like my mother’s. I drove back to the pharmacy and showed it to the pharmacist who shrugged and said, “I don’t have time to check the first names.” Needless to say, that was the last time I used this drug store chain that begins with a “W”. It’s frightening to think how many times this might have happened with this pharmacist.

Mail order pharmacies can be a danger. The one my husband used could not even get a demand to stop auto refills right. and we received a total of over a years supply at one time. We reported it, and they did credit us. Then it happened two more times. That is when we discontinued use of that service and switched to a local source. I felt that if the mail order pharmacy could not even get the stop auto fill request right, then I could not trust them to dispense accurately. I miss our independent pharmacist, even though he worked through a local grocery store. When he retired, we felt like a friend had been lost.

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