When hindsight is 20/40, it is time to find a new pharmacy

As the 46% of Americans who take prescription drugs know, pharmacies are boring. You walk in, wait in line, hand over some money, and in turn receive a small orange bottle in a paper bag.  It was no different when I went with my partner to the University Village QFC to pick up her prescription.

After leaving the pharmacy, we ran to her car through oil-slicked puddles in an attempt to avoid the rain (oh Seattle).  Right after we entered the refuge of her car, my partner got out her pill bottle to take the morning dose of her medication.  As I started the car, she opened the bottle and a capsule rolled into her palm.  “That doesn’t look right,” I said.  My partner takes lithium, a drug I am fairly familiar with through my past work in inpatient psychiatry.  This pill looked completely unfamiliar to me.  “I have never seen any lithium like this,” she said in agreement.  She turned the bottle around to reveal a label with a name, birthday, and medication name completely different than her own.

“Clindamycin 150mg”.

My heart began to race and I could feel all the physiologic discomfort of a fight or flight response. (If only they had mistakenly given given my partner propranolol… sigh)  “I’m really sorry,” I said to my partner as a forewarning, “but I may end up being pretty confrontational.”

This was, after all, one of the many medication error scenarios I recently spent discussing, dreading, and anticipating throughout nursing school.  I also knew that these types of situations don’t just happen by mistake.  For every minute dedicated to discussing medication errors in school, many more were spent learning how to avoid such errors.  In pharmacies as in hospitals, there are systems in place designed specifically to prevent such errors from occurring.  Often when errors do happen, it is because health care workers aren’t using these systems properly.  In short, someone wasn’t doing their job.

We walked back to the counter.  The pharmacy technician greeted us with a look of surprise and, likely in response to anger written on our faces, concern. 

“What seems to be the problem?”  The clerk inquired.

“You gave me the wrong medication.” my partner shot back. 

The pharmacist became flustered.  “You didn’t take it did you?  Are you allergic?”  Finally it came out.  “I am so sorry.  Let me get you the right medication.” 

As I heard this I found myself faced with two options.  One, accept the apology, keep my mouth shut, and leave.  Or two, hold the pharmacy accountable for their error and ask what will be done to prevent such errors in the future.  I chose the latter, because like many nurses, I identify as a patient advocate. While nurses sometimes fall short, we ideally should challenge authority and hierarchy for the sake of our patients.  Such moral obligations are even written into our laws.  Nurses are mandatory reporters of neglect and abuse (among other things), not only at work, but in the community as well.  While I had no legal obligation to hold this pharmacy accountable and push them to implement safer practices, I felt an undeniable moral obligation.     

“Listen,” I said making no attempt to hide my frustration.  “This wasn’t a mistake. This was negligence.  There are systems in place to prevent this.  We both know your job is to check to make sure you are giving the right patient the right drug and you didn’t even look at the bottle.  As a nurse, I have patients that use this pharmacy.  I don’t want an apology; I want to know what you are going to change to make sure this doesn’t happen again.”

Either due to my playing the nurse card, or perhaps being a good person (though I’m always skeptical of pharmacists and dentists), the pharmacist conceded that yes, it was negligent and it was not simply a mistake. She explained that there was a system in place that evaluates these events and changes are made to prevent them from happening in the future.  With that, and the right medication (given free of charge), we left.

It was determined that the barcode on the pill bottle was covered by a “Take with food” sticker.  Normally, the pharmacy technician is supposed to scan the barcode on the bottle and the paper insert to make sure they march.  In this case, the bottle couldn’t be scanned due to the sticker.  Feeling rushed by a sizable line at the counter, the pharmacy technician simply handed my partner the prescription rather than taking the time to look at the bottle to make sure it was correct.  Yes, this was negligent, but it was also a system that made doing the right (safest) thing more difficult.  Whether one is in healthcare, designing computer systems, or a factory assembly line, systems should be designed in such a way that makes the right thing to do the easiest thing to do.  An example would be having the sticker with the name and medication also have the “take with food” instructions on it.  With only one sticker, there would be no way to cover the barcode.

I expected, perhaps naively, that next time I came in barcodes would no longer be covered.  Not so.  When I picked my own prescription up a few weeks later, the barcode was covered by another sticker.  I raised this concern a second time, and was brushed off with a “We will work really hard not to put stickers over the barcode.”    

As a result, I now get my medications at Bartell Drugs in University Village.  Unlike QFC, when the prescription label prints out, it has the medication warnings and instructions printed on the same label, completely eliminating the possibility of another sticker covering the barcode.  I sincerely hope QFC implements safer practices.  Until they do, go elsewhere.      


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