pharmacy shelves

Fun thing to try: web search pharmacy prescription error rates.  See what you get.   Well, maybe not so much fun as possibly terrifying, but of note, there is no ‘national’ or ‘local’ prescription error rate.  More so, there is no error rate for clinically relevant errors versus non clinically relevant errors. I think I’ve made this point before (back in the good old days when I actually had Facebook), but a few recent customer interactions have dredged up old irritations.   I promise I’ll circle back around to the error part later.

Let’s start with the fun part.  All pharmacy patients fall into a category. Obviously there are categories that are better than others. There are some categories, and I think they’ll become obvious, that make every pharmacist want to curl up in a little ball and wish it would all just go away. If you possibly fit in one of those categories, please find the nearest pint bottle and hit yourself in the head with it.  Better yet, go to your pharmacy, talk to your super awesome pharmacist, and ask them to belt you with a bottle of metformin (not the little 100 count bottle, that big-a** 1000mg 500 count bottle that sits like a fat elephant on the shelf).  Or you could just give them a case of beer, I’d go for that (Deschutes or Stone are good choices).

The I’ve got this patient.  They have everything together.  Their poo does not offend.  They are so great they are even better at my job than I am.   They are above illness, but by golly if they have to be on meds they’re gonna conquer it like everything else. If their med color changes they’re on that phone calling the pharmacy before I’ve even put the pills in the bottle

The been there done that nurse.  Don’t even offer to counsel.  They’ve been there, done that, got the t shirt.  They’re apparently a pharmacist, doctor, physical therapist, and psychiatrist all rolled into one person so don’t even try to tell them what they don’t want to hear, because they will always know better.

The hobbyist. This patient knows just enough to be dangerous. They are competent, but may still need guidance from time to time, but due to their self reliance are resistant to guidance, and like a teenager will often do the opposite as instructed. They’d rather Google the answer than be seen asking for help in the pharmacy. Apparently mineral oil enemas are still a thing. When they do ask for help, they’ve already Googled it, done it, and wonder if they’re gonna die. Usually I answer yes just to watch it process.

The competitor. They have many drugs. They display their drugs like trophies. Family dinner conversation often revolves around disease severity and how many new meds they’ve tried recently. They may even do a pick-up match in the grocery store. The winner has the most diseases and the most drugs and can eloquently explain all of them in detail. They are similar to the hobbyist, but recognize their pharmacist as the coach to help give them the edge in those intense conversations.

The amateur. They don’t really know much about their issues. They can tell you about half of their meds, but don’t expect them to know what they are all for. They ask questions frequently, but don’t usually follow up, nor do they usually follow directions. They usually are the callers that just say fill everything that I need. Coming soon: Bottles with cloud connectivity so that I don’t have to rely on my ESP to know exactly what you have left in that bottle. Won’t matter, it’s almost always the pill not filled for the last six months and now they’re gonna die if they don’t get it like yesterday. They prefer to listen to the hobbyist or the competitor because uber pharmacist intimidates them.

The don’t know don’t care. Pretty sure if I put rabbit poo in a bottle and told them they had COVID-19 and I had the drug to cure it they would take it. They are the “looks close enough” crowd. They know that they’ve got a pill somewhere inside our computer that’s white and round and about the size of a pea and they got it 3 years ago but don’t remember why only that it kept them from dying and they need it like yesterday so it would be great Uber pharmacist if you’d fill that. Do not put them in the same room with the competitor or the Uber organized, but like the amateur they assume pharmacists are all knowing and know exactly what they need when they need it before they need it.

The how dare you say I need medication. Sightings of this patient are rare, but avid watchers may catch a glimpse of these patients about two or 3 weeks prior to their bi-annual or annual exam, usually so they can say they’ve been taking their meds. Any other time of the year we place 15 calls to remind them to get their medicine in the hopes of a sighting.

So, what’s the point? Going back to our web search, you won’t find a true error rate. Anywhere. Doesn’t exist. Probably the best example of a study that attempts to determine a true error rate lies in a 2003 observational study (opens PDF) that looked at 50 national pharmacies. This particular example concluded that a pharmacy doing an average of 250 prescriptions a day would make 4 errors. That’s 91,250 prescriptions a year, or an error rate of 1.6%. The clinical severity of these errors was graded as well, and of 77 errors identified only 0.1% of those actually resulted in an error of clinical significance. Here’s the problem: other studies have determined error rates as low as 0.1% to as high as 10%. None have produced compelling evidence that correlates a specific work condition or issue with increased errors.

Fun fact: pharmacists are perfectionists. We have to be. We are in a job that aims for 100% accuracy 100% of the time. Of those 91,250 prescriptions, only 2 (maybe 3) individuals will be responsible for verifying the complete accuracy of those prescriptions. 4 errors a day. Any could be lethal. But wait, we’re assuming that there is only one person responsible for the accuracy of those prescriptions.

Fun fact number 2: You as the patient are the best and most qualified advocate for yourself. You are also the only individual that has been provided the information to know exactly what you are taking and why you are taking it. We the pharmacy do not have access to your cardiology chart nor your primary care chart. Likewise, your primary care does not see what we fill, and they may not see the cardiology chart either. The one common denominator is the patient.

So of those categories above, who is the most cringeworthy? Not the I’ve got this bunch or even necessarily the been there done that nurse. The hobbyist and the competitor, while sometimes deserving of a bottle over the head for being a public nuisance, are usually on top of it. Nope, it’s the bottom three that are the bane of our existence and occupy 80% of our time. How many errors could be avoided if the patient where to take responsibility for their own healthcare and actually perform that last safety check behind their pharmacist?

You as the patient are the best and most qualified advocate for yourself

I remember seeing a case a few years ago from another pharmacy. This case was in front of the Board, as a young child had been given a bottle that was mislabeled (the wrong drug was entered into the pharmacy software and dispensed) after an emergency room visit. Unfortunately that child passed away because of complications from the error, as he was given the medication exactly as it said on the bottle. Something that crossed my mind was that when I have had to go to a local ER or urgent care, they always provide discharge instructions with the same directions and drugs as the prescriptions to be dispensed. I’m not assigning blame anywhere in this tragic circumstance, but could it have been avoided if the parent/caregiver had read the discharge instructions to know exactly what to expect, and then proceeded to question why the label had something different on it? We are the most trusted profession, but even heroes have sidekicks. Be the sidekick, take control of your health.

Did I just do that?
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