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Pharmacy Error: When the Prescription is Wrong

Pharmacy Error: What Can Go Wrong?
Pharmacy Error & Prescription Problems

Prescriptions are meant to be followed exactly.  When pharmacy error happens serious complications can result. Top pharmacy errors include giving the wrong medication and providing incorrect dosage information.  Sometimes patients receive someone else’s medication.  Any of these things can send a person to the hospital or cause death.  The Journal of the American Medical Association reports approximately 100,000 Americans die annually due to “adverse drug reactions”, placing drug reactions as one of the six leading causes of death in the country.

Medications are supposed to heal and maintain health. What dangers result when things go wrong?

Pharmacy Error Causes

The most common pharmacy error involves providing incorrect dosage information. Sometimes the pharmacist or pharmacy technician is unable to read the physician’s notes.  It can be confusion of decimal points since a dosage of 2.0 may be misinterpreted as 20, leaving the patient to receive a dangerous dose 10 times the amount actually prescribed by the patient’s physician. Overdoses are often a tragic direct result of this colossal error.

Allergic reactions are another form of pharmacy error. A patient may be prescribed a drug that their insurance does not cover, so the pharmacy provides a substitute that insurance will cover.  The pharmacy is required to discuss such changes with the prescribing medical provider first.  But with the demand and pressure placed on the pharmacy, and the difficulty of getting through to the prescriber, such contact often does not actually happen.  This lack of required communication can cause dangerous allergic reactions, resulting in serious injury, addiction, permanent mental or health problems and in the most extreme cases death.

A joint study by the pharmacy underwriting group CNA and the Healthcare Providers Service Organization (HPSO) found that 43.8% of all pharmacy error claims stemmed from dispensing the wrong medication. The majority of those were attributed to drugs with similar names. The most often improperly dispensed drugs were Klonopin, Clonazepam, and Gipizide instead of the prescribed Clonidine. These incorrectly dispensed prescriptions can cause injuries including vision loss, brain injury or death.  Brain injury is the most common permanent injury caused by pharmacy error.

Legal Elements of Pharmacy Error Liability

Victims of pharmacist or technician error may be entitled to receive compensation for pain and suffering, medical costs, and future medical expenses. These cases can be difficult to litigate because the victim has to prove duty, breach, causation, and damages. Although statistics prove that most often it is the pharmacist’s negligence that caused the prescription error, there have been cases in which the physician prescribed the wrong medication to the patient.

To disprove liability for non-strict liability cases, the pharmacy, manufacturer, or pharmacist must show how these elements were not proved by the claimant. If the claimant successfully proves the elements, then the pharmacist may argue contributory negligence depending on the circumstance, meaning the claimant contributed to their resulting injury due to failure to follow the administered counseling. However, when all elements for liability are met, a large sum of compensation is often awarded to the victims.

Establishing a pharmacist’s legal duty is clear. Pharmacists are licensed and hold the duty to properly dispense medications, with correct dosage information.  There is also a duty to provide counseling.  Pharmacists and pharmacy technicians also hold a duty to make sure the drug you are prescribed will not dangerously or negatively react with other medications or drugs you may be taking and to ask about allergies you may have.

Who is Liable for Pharmacy Error?

Prescription manufacturers, pharmacies and the ‘big box’ retailers that provide pharmacy services can be held liable for prescription error. But it is rare that pharmacy technicians themselves are held liable.  Some see this as a disincentive for pharmacy technicians to review their work for accuracy or to be more thorough during the process of dispensing the prescription drugs, causing an increased risk of prescription error to occur.

Occasionally prescription error aggravates a preexisting condition. It is typically safe to assume that the patient was experiencing some form of physical or mental illness to be prescribed a prescription drug. Nonetheless, the pharmacist or pharmacy faces liability to the extent that their negligence worsened the condition.  This aggravation or preexisting condition can include lengthening the course of recovery, increasing the severity of the underlying condition, jacking up medical expenses or even death.

Some drugs are considered so inherently dangerous that the manufacturer or provider can be held strictly liable for injuries resulting from the medication. This relieves the injured party or their heirs from the legal requirement of establishing negligence.  In those cases in which a patient dies as a result of pharmacy error, family members may file a wrongful death suit.

The CAN/HPSO research confirmed that prescription errors involved with minors received an average of $196,000. This is a large sum, but minor victims only make up 15.4% of the claims involved in the study. Although adults in the age group of 18-64 received a smaller average of $52,031, this group had the largest volume of claims. Those over age 65 made up 29.6% of all claims and their average compensation was $78,321.

Other eye-opening CAN/HPSO findings:

  • 46.3% of all claims were errors by privately owned pharmacies
  • 34.6% of claims attributed to national chain pharmacies
  • 4.3% of claimed errors were by hospitals
  • 11.7% of all claims resulted in permanent patient injury or death
  • 13.6% of claims resulted in overdose

The risk of pharmacy error increased following passage of the Affordable Care Act. The rising demand for medications following implementation of ACA brought more pressure upon pharmacies.  Increased demand significantly increases the risk of error.  According to the National Association of Chain Drug Stores (NACDS), Americans purchase over 2 billion prescriptions every year.  With pharmacists often working a minimum of 60 hours each week the statistical risk of error is obvious.

There are a variety of reasons as to why these harmful errors keep occurring. The most common causes of pharmacy error include identifying patients incorrectly, inaccurate computer codes, pressure from long lines of patients outnumbering staff, inadequate attention to each prescription, and sometimes a patient’s failure to obtain counseling from the pharmacy. Human error underlies all of these causes and could, in theory, be prevented.

Steps for Pharmacy Error Prevention

To avoid errors, pharmacists must pay closer attention to each prescription and follow the doctor’s instruction perfectly so an error doesn’t change someone’s life or end a person’s life. To assist with minimizing the risk of error and reduce the risk of admittance to rehab, pharmacists have required check offs they must complete before dispensing a drug to a patient to keep the risk of error minimal. Still, many mistakes happen because staff is overworked with long hours without time to rest. A study in New Jersey proved to be disappointing because out of their observation of 9,846 filled prescriptions, 1,371 of these filled prescriptions were in some form incorrect.

Consumers can reduce the risk of harm resulting from pharmacy error with several steps:

  • Always check your prescription item to make sure it’s exactly what the health care provider intended
  • Seek and listen to counseling provided by the pharmacist
  • Notify the pharmacist of all other medications, supplements, and drugs you may be using
  • Discuss allergies
  • Take the proper dosage
  • Inform the pharmacist or the technician of the reason for taking the specific medication.  This provides an opportunity to catch errors caused by similarly spelled prescription items

Pharmacists face not only time constraints, but additional stress comes from numerous federal regulations. These include a requirement to accompany each prescription with counselling before the customer leaves the store.  When this step is skipped, as is often the case, the lack of proper understanding can cause overdoses and other severe injuries.

NACDS expects pharmacies to hire 8% more pharmacists in an attempt to keep up with the growing demand for prescription drugs. However, it is expected that the demand for prescription items will increase by 27%, causing pharmacies to continue to be shorthanded, despite the additional staff.


Proof of prescription error is addressed in another article available here.

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Attorney Myers is a member of the American Trial Lawyers Association, Massachusetts Academy of Trial Lawyers, and New Hampshire Trial Lawyers Association. The Law Offices of Andrew D. Myers offer a broad range of legal services in personal injury cases in Massachusetts (MA) and New Hampshire (NH) areas.

The information on this web site is offered for informational purposes only. It is not offered as, and does not constitute, legal advice. Laws vary widely from state to state. You should rely only on the advice given to you during a personal consultation by a local attorney who is thoroughly familiar with state laws and the area of practice in which your concern lies. This web site must be labeled advertisement in some jurisdictions.