In need of a system: tracking pharmaceutical errors

In the US more than 100,000 Americans die each year of adverse drug reactions. That is, according to the Journal of the American Medical Association who also notes that death from adverse drug reactions is the sixth leading cause of death in the US.

Of those 100,000 deaths, no one really knows how many are related to pharmaceutical dispensing errors. The journal, ACS Chemical Neuroscience, reports that in the US, there were 4.02 billion prescriptions dispensed in 2011.

Phillip Grauss, a senior pharmacist at Kaiser Permanente in Petaluma, California explains that pharmacists are legally responsible if a mistake is made, but pharmacy technicians have no legal responsibility. This often means they may lack incentive to double check the prescriptions they’re handing out. He also says pharmacists are required by federal law to counsel customers about prescription drugs.

In Canada, there are approximately 38,000 pharmacists dispensing more than half a billion prescriptions each year with little mandatory reporting and absolutely no national tracking system for pharmacists who make mistakes.

“We’re doing a lot of good things, but there are still a lot of patients that suffer harm. And so it’s definitely an issue that we need to give more resources and attention to,” says Neil MacKinnon, a Canadian pharmacy error researcher and dean of the school of pharmacy at the University of Cincinnati.

An investigation into Canadian pharmacies found that when requesting a Schedule 2 drug – that is non-prescription medication kept behind the counter – more than half of them failed to provide medical counseling and none of them provided warnings or flagged possible interactions with other medications.

Although Nova Scotia is the only Canadian province that has made tracking tools mandatory, and Saskatchewan is running a pilot project, chair of the Canadian Pharmacists Association, Jane Farnham, says there is little reason for people to become concerned.

She says, “We have, to my knowledge and to my belief, one of the safest medication systems in the world,” even though there’s no national system to collect pharmacy errors, “we’re moving in a direction of much more voluntary reporting.”

An independent non-profit, Institute for Safe Medication Practices Canada, continues to work toward implementing a mandatory national tracking and reporting system for pharmacies.

Certina Ho, institute project leader, says that common mistakes include substituting drugs and look the same or sound the same or misreading handwritten prescriptions. Often, he says, these types of errors are caught, but when they’re not, the result can be devastating.

With the exception of a few American states, US pharmacies are also not required to report errors that involve serious injury or death. There are no federal requirements, so no one knows just how many errors occur.

In the 1990s, a study involving 1,116 hospitals that reported information on medication errors showed errors occurring in 5.07 percent of the patients admitted each year to these hospitals. Each hospital experienced a medication error every 22.7 hours (every 19.73 admissions).

In 2003, a study of dispensing accuracy rates in 50 pharmacies located in 6 cities across the U.S. found an overall dispensing accuracy rate of 98.3 percent.

A report from researchers at Ohio State University estimated that in 2007, there were 5.7 errors per 10,000 prescriptions or 2.2 million dispensing errors a year.

US figures have not been updated since 2007.