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 Dehumanizing Drug
Dispensing
By Stephanie Steward
Assistant Editor
Just how common are pharmacy errors? It may be a hard question to
answer. However, recent reports about such mistakes out of San
Antonio, TX, paint an alarming picture. And this was just one city
in one month.
KSAT.com San Antonio reported that a nine-month-old San Antonio boy was given a steroid
instead of the prescribed antibiotic. He ended up in the emergency
room after suffering from hyperactivity. Four days later, KSAT.com
reported that a nine-year-old schizophrenic and bipolar patient was given the wrong formula of depakote.
He is now at risk for liver damage. In response, Walgreen's claimed
that pharmacy errors are rare. But in the Institute of Medicine
(IOM)'s report, Preventing Medication Errors, the authors write
that anywhere from 1.7% to 24% of prescriptions are erroneously
dispensed. Even if the most recent study, which puts the error rate
at 1.7%, best represents reality, it still means that 51.5 million
errors are made during the filling of 3 billion prescriptions each
year, the authors write.
 Medication errors have
been blamed on long work hours impairing the judgment of exhausted
medical professionals, safety and storage procedures not being
followed, and difficulty discerning between products that are
similarly packaged or named. In other words, these errors are blamed
on humans. The human dispensers.
Could humans be removed from the process of drug dispensing? Not
entirely. But perhaps some of the responsibility could be taken off
of the end-of-the-line handlers (pharmacists and nurses) and put
back on creative package designers. At the very least, if most
brands of gum are available in blister packs, surely more drugs
could be packaged in easily identifiable, premeasured doses. We
don't necessarily need a fully automated pharmacy that resembles a
sterile vending machine. But perhaps we could reduce the amount of
pill counting pharmacists have to do.
The IOM report made specific recommendations for healthcare
organizations, federal agencies, and industry to address preventable
prescription drug errors. To eliminate possible misreading of
handwritten prescriptions (to finally rid the world of doctors'
notorious chicken-scratches), the report recommends that "U.S.
healthcare providers must move away from paper-based prescriptions
to the electronic prescribing of drugs by all providers by 2010."
Such a suggestion seems completely realistic considering how
prolific personal digital assistants (PDAs) are among professionals
anyway.
 The report also suggests
that FDA, the Agency for Healthcare Research and Quality, and the
pharmaceutical industry should collaborate with the United States
Pharmacopeia, the Institute
for Safe Medication Practices, and other appropriate
organizations "to develop a plan to address the problems associated
with drug naming, labeling, and packaging by the end of 2007." How
difficult or costly would it be for packagers and pharmaceutical
companies to make sure that child and adult doses of drugs are
packaged in completely and vividly different colors? Certainly
nothing compared to the cost of losing lives.
These are reasonable and necessary calls for action from the
industry. Healthcare professionals aren't all of a sudden going to
be more rested and able to eliminate their own human tendency to
err. A tired pharmacist or nurse is much more likely to choose
correctly between two different sizes of dose packs than he or she
is to accurately count out dozens of pills into a vial. The power to
change these horrifying statistics is in the hands of packagers.
Stephanie Steward
Assistant
Editor | 
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