If you think Dobutamine and Dopamine or prednisolone and prednisone sound really similar you’re scarily right, and the medical profession would agree with you. There a horror stories of the effects of being given Navane instead of Norvasc by mistake at the pharmacy. A study by John’s Hopkins University attributed 10% of all deaths might be the result of patients being given and taking the wrong medicine. Death by mistake doesn’t sound all that good to me.
How do errors happen?
In a business with humans involved it is easy to make a mistake. Pharmacists have been known to put the prescription of one patient into the bag of another. Often pharmacies seal the bag, the patient doesn’t look at the medication until they get home and even then there is a possibility they will not notice there’s a difference unless they notice there’s a change in dosage.
Patients might get the right drug but at the wrong dosage levels, this can happen for all sorts of reasons, the pharmacist might not know how to override the defaults on the system or perhaps don’t even know they can do so.
When moving from hospital to home is another time when there can be mix ups between systems. Insulin is particularly susceptible as there is no standard concentration in insulin product. Hospitals can be using a different concentration than the patient uses as an outpatient, the risks are self-evident.
The complexities are evident
There are so many different places where the system can fall down that it is no surprise when it does so. Drugs with names which are close, different systems between doctors prescribing and the pharmacists dispensing, computer systems with override drug interaction warnings, the ease with which the wrong strength could be taken are all points where errors can occur.
Add to that a succession of people who are working fast and under pressure too, the results are predictable and the law of statistics say there are going to be too many errors because there are so many combinations of places where things can go wrong.
Fixing the issue is not easy
There is one thing that would go a long way to fixing the issue, but it is one thing that pharmacists have precious little and that is time.
Not closing the bags until they are handed over to the patients, for example, will help reduce the number of time patient one gets patients two’s prescription. Adding in technology which is consistent from prescription to dispensing is another.
Discussing drug names and details with the patients is also an important part. Some patients may find it hard to come to terms with complicated drug names. But on the other hand, most of them have a vested interest in knowing what they take and why. The extra counseling needed will take time, but if it is life-saving time, then it has to be worth the effort.