Protecting Your Family from Prescription Errors
“After that day, I wasn’t the same person.”
After years of trying to get pregnant, followed by a difficult pregnancy, Maria Rique Gamboa and her husband met their miracle son, Daniel, in late 2016. Due to health concerns, Daniel was delivered early at 31 weeks. He only weighed about three pounds.
“When I gave birth, the doctor told me, ‘Don’t worry, you’re not going to even see the baby, because a team of doctors are waiting for him in the NICU and they need to check everything on him,’” Maria said.
Maria had preeclampsia and says her blood pressure was dangerously high for her and the baby. She said the medical decision was easy — deliver the baby early so doctors could treat her and Daniel separately. The two survived delivery, but Maria’s blood pressure was still elevated.
“They didn’t want to take me to the NICU because I was going to be stressed out and my blood pressure was going to be up,” she said.
After she was discharged from the hospital, the doctor prescribed her the blood pressure medication Labetalol. They filled the prescription at a CVS down the street from the hospital, but Maria said she was feeling worse a day after taking the medication.
“I was in the NICU with my baby and I completely blacked out,” she said. “I saw very blurry, I don’t remember. I started sweating; my heartbeat was so high.” Maria told Team 10 her blood pressure skyrocketed to life-threatening levels.
“The doctor said, there’s no explanation why the blood pressure isn’t going down if she has the medicine in her system,” she said. Maria believes she had the right medication, but said the pharmacy gave her the wrong dosage.
According to a lawsuit filed against CVS, “the Plaintiff presented to Defendant CVS a prescription for Labetalol 400 mg, however, the Defendants, and each of them provided the Plaintiff with Labetalol 100 mg to be taken twice per day. The Defendants and each of their negligence in providing the incorrect dosage resulted in the failure to adequately control the Plaintiff’s postpartum hypertension and she was subsequently hospitalized.”
Team 10 investigator Adam Racusin asked Maria if she ever thought a pharmacy would make a mistake like that.
“I never thought of that before,” she said.
“It’s not something that is uncommon I just think it’s not often reported,” said Maria’s attorney. He is claiming professional negligence on the part of CVS and the pharmacist.
“If there was any dispute or any doubt in the pharmacist’s mind or the pharmacist technician’s mind all they had to do was call the doctor, and actually they are under an obligation to call the doctor to clarify,” Maria’s attorney said.
In a statement, a spokesperson for CVS wrote: “The health and safety of our customers is our number one priority and we have comprehensive policies and procedures in place to ensure prescription safety. Prescription errors are a very rare occurrence, but if one does occur we determine what happened in order to prevent it from occurring again. We have apologized to the Gamboa family regarding this incident. We remain committed to ensuring that prescriptions are dispensed safely and accurately to our patients. Due to the pending litigation, we have no further comment regarding this matter.”
Maria recovered but said her breast milk supply suddenly stopped as a result of her blood pressure episode. Daniel was too young for formula, so they had to rely on donor milk to keep him alive. He’s a little bigger now, but Maria said she’s still haunted by the thought that she could have missed her son’s smiles, laughs, and first steps.
“After all that happened (to) leave him without his mom, just by thinking of that gets me worse,” she said.
No Reporting Requirements for Medication Errors
Team 10 spent weeks sifting through disciplinary and enforcement actions taken against pharmacists and pharmacies. We discovered the California Board of Pharmacy [pharmacy.ca.gov] issues hundreds of citations to pharmacists each year for dispensing errors, but errors are only what the state knows about. In California, according to the statue pharmacies are not required to report a dispensing error.
“We think that their time is better spent focusing on what led to the error and to correct the error and to train around the error so it doesn’t reoccur making the marketplace safer,” said California Board of Pharmacy Executive Officer Virginia Herold.
Herold has been with the agency for nearly three decades.
She said the board relies on consumer complaints and court settlements to identify wrongdoings. It can and does investigate and discipline.
According to information obtained by Team 10, the board received more than 3,000 complaints during the 2016/2017 fiscal year. During that timeframe, it issued more than 2,000 citations for pharmacist and pharmacy wrongdoings and referred more than 350 cases to the California Office of the Attorney General.
Herold said pharmacies are required to keep records of all dispensing errors. After a mistake, the pharmacy must initiate a quality assurance review, looking at what happened and who is responsible. We desperately want patients to complain to us and tell us. – Virginia Herold, Executive Officer California State Board of Pharmacy. They are required to keep those records for one year.
“We strongly believe that pharmacists do not deliberately make errors,” Herold said. “If they do, that would be a formal disciplinary matter and we would move very quickly to remove them from practice.” Herold said consumers need to be their own advocates and not blindly take a medication. The easiest way to prevent a dispensing error is to take the time to talk to the pharmacist.
“In California pharmacies, every time you get a new medication the pharmacist is required to come talk to you,” Herold said. “They are not required to have someone ask do you have questions for the pharmacist, or would you like to talk to the pharmacist, the pharmacist is required to come down and initiate a conversation with you about how to take that medication. If that does not occur, we desperately want patients to complain to us and tell us, because that is one of the single greatest ways that the pharmacy and the patient can prevent an error from reaching you.”
Training a New Generation of Pharmacists
At the UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, instructors are training the next generation of professionals.
“It is a very rigorous program,” said Dr. Eduardo Fricovsky, an associate clinical professor.
“Many say that compared to medicine, it’s just as hard and difficult.” Fricovsky is a licensed pharmacist and teaches first-year pharmacy practice.
“It covers all the non-prescription medications, over-the-counter products that are available,” he said. “I don’t know if you’re aware of this, but there’s over 200,000 over-the-counter products, not only including medications, but other items like first aid and supplements and minerals.”
While the program might start off with everything but prescription medication, as the years go on the coursework picks up. Fricovsky said students will eventually become a walking drug encyclopedia. They will put that information learned into practice.
“We do simulations,” he said. “We want students to go into a scenario that will make them a bit uncomfortable because they don’t know what they are being presented with. Sometimes we have scenarios where there’s a prescription error and we see how they handle prescription errors, you know always making sure that they have the patient’s safety in mind.” Always take the time to talk to your pharmacist, especially if it’s a new prescription. – Dr. Eduardo Fricovsky
According to the school’s website [pharmacy.ucsd.edu], the curriculum is dynamic and under frequent revision. The purpose of the four-year program is “to prepare students to be leaders in the profession of pharmacy and to provide them with the tools to effectively practice in a wide variety of currently existing and potential future roles in hospitals and medical centers, community pharmacy settings, academia, government and the pharmaceutical industry.” While students can head straight into a retail setting, there’s also continuing education opportunities in a health care profession that’s expanding. With everything they learned in school, Fricovsky said consumers should take advantage of their pharmacist’s education.
“Always take the time to talk to your pharmacist, especially if it’s a new prescription,” he said. “By law we have to offer a consultation to patients, but patients have the right to refuse if they wish.”
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