Posted by Elisabeth Leamy, Thu Jul 27 2006, 08:45pm

SERVICES: Pharmacy Foul-ups

SERVICES: Pharmacy Foul-ups

Every year, 1.5 million Americans are injured or killed by medication mix-ups. And if you land in the hospital for some reason, errors there are so frequent you could be subjected to a new one every day of your stay. Those heart-stopping statistics come courtesy of a new report by the prestigious Institute of Medicine.
7-year-old Zachary K. has a rare genetic disease that weakens his immune system. So he takes a small dose of antibiotics every day to try to ward off illness. At one point, Zach's mom, Cynthia, noticed that his pills looked different. She was right. Turns out, the pharmacy had dispensed the right pills in the wrong strength –double strength. Cynthia complained to the pharmacy, turned in the bad bottle and thought nothing more of it. Until it happened again a month later. The same pharmacy had made the same mistake twice.

Spencer P. suffers from serious sinus problems. His doctor prescribed a new medication and he took it with high hopes. But Spencer immediately suffered devastating side effects: dizziness, difficulty breathing and tightness in his chest. He missed several shifts at his day job and had to quit his night job. Spencer kept taking the medication, hoping the side effects would wear off and the drug would begin to work. After a month, he couldn't take it anymore and went to see his doctor. What a shock! The doctor had prescribed a nasal spray called "Flonase." The pharmacy had dispensed a prostate drug called "Flomax."

Why do medication mix-ups like this happen? For one thing, there are more prescription drugs on the market than ever before, an awful lot for a pharmacist to remember. To make matters worse, some of them have similar names –like Flonase and Flomax, Celebrex and Cerebyx, Lamisil and Lamictal. If a prescription is called in --or written in a doctor's famously messy handwriting-- it's easy to see how a pharmacist could get it wrong. Plus that pharmacist is probably overworked. Prescription drug use has doubled while the number of pharmacists has remained the same.

The three most common mistakes are dispensing the wrong drug, dispensing the wrong dose and giving the wrong instructions. It's hard to say how often pharmacy foul-ups happen, because many states don't require pharmacists to report their errors. When consumers complain, often state pharmacy boards (made up of other pharmacists) dole out light punishments. Until pharmacists are able to spend less time putting pills in bottles, you'll have to pay more attention to what you're putting into your body.


1. Know the size, shape, color and strength of any pills you take routinely.
2. If you are trying a new medication, ask your doctor for a sample or ask to see a picture of the drug in the Physician's Desk Reference. You can also go to the Physician's Desk Reference website at
3. Many doctors now write prescriptions on a computer. If not, be sure your doctor writes neatly and ask him to identify the drug by both the generic and the brand name.
4. Also ask your doctor what the medication is most commonly used for, how to take it and what the side effects are.
5. Then ask the pharmacist those same questions and make sure the explanations match.
6. Finally, note the strength and instructions your doctor had in mind and make sure the pharmacist fills the order as intended.

Voice your concerns to your state's board of pharmacy. Also file complaints with the BBB and county and state consumer protection offices.