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“20/20” captures community pharmacy errors, but vision seems to be shortsighted

From the April 5, 2007 issue

Last Friday (3/30/07), many television viewers tuned in to 20/20 (ABC) to watch the much-advertised exposé on prescription errors, “A prescription for disaster.” (To view an expanded version of the program, visit: Index?id=3002095.) According to the producers, the segment was intended to provide answers to two very important questions:

  1. Who is the person behind the counter filling your prescription?
  2. Are you getting the medication your physician prescribed?

Unfortunately, the program seemed to miss its mark on both accounts.

When describing the “person” behind the counter, the role of the pharmacist was scantily depicted. Most of the program’s attention was focused on pharmacy technicians and their lack of training. Yes, pharmacy should set consistent standards for training and certification of pharmacy technicians and better define their role in the dispensing of medications. However, regulatory bodies need to enact these changes and insurance reimbursement systems need to financially support the regulations or progress will continue to be slow. The only role of the pharmacist that was highlighted in the segment was patient counseling. This is a critical process, but also a challenge since many patients don’t understand the value of counseling and have unknowingly declined the opportunity to speak to a pharmacist. In the end, the segment failed to inform the public about the “pharmacist” behind the counter and his or her role in supervising the technician’s work, reviewing the safety and appropriateness of prescriptions, querying the insurer to verify and maximize coverage, checking the completion of all prescriptions before dispensing, and detecting and resolving possible prescribing errors. In fact, the program failed to inject balance by mentioning the occasional prescribing errors uncovered and corrected by pharmacists.

In answer to the second question, the 20/20 investigative staff interviewed two patients and families of patients who had suffered harm from a medication error— a woman who suffered a stroke after the pharmacy dispensed warfarin 10 mg instead of 1 mg, and a child who sustained brain damage after receiving an oral diabetic medication instead of phenobarbital. These testimonials were unquestionably moving. Fortunately, harmful errors like these clearly represent an extreme minority given all the prescription medications safely dispensed each year. Nevertheless, harmful errors like those depicted on 20/20 should never happen. The investigation also uncovered a “22% error rate” during the dispensing of 100 prescriptions. However, a single statement practically glossed over during the show noted, “no patients received the wrong medication.” The 22% error rate was based on less significant, non-clinical details of a prescription such as counting out the wrong number of pills and failing to put a childproof cap on a bottle. The more significant clinical components of the prescription such as the right drug, right dose, and right patient appeared to be correct, but no details were provided.

Regardless of the inconsistencies listed above, perhaps the biggest mark that the 20/20 exposé missed was the opportunity to inform consumers about the important role they can play in medication error prevention. Yes, the segment likely alarmed consumers, but little substantive advice was forthcoming about ways consumers can help to prevent errors. Simply describing the importance of counseling and urging the public to demand it when picking up a prescription would have made the segment much more worthy of attention. Unfortunately, we can’t say with confidence that the 20/20 segment will do much to improve the likelihood of this happening. The program also failed to mention any safety features already present in many pharmacies today that have helped to improve safety in the last 5 years, including electronic prescribing, bar coding, pill imaging, sophisticated drug interaction software, and so on.

With this said, we must also agree with Ken Barker and Elizabeth Flynn, researchers who helped create the undercover investigation for 20/20, that the exposé should serve as a wake-up call to develop technician training and certification standards, consistently offer to counsel all patients when picking up prescriptions, change reimbursement systems to acknowledge and compensate the time pharmacists spend during clinical review of prescriptions and patient counseling, improve error reporting and disclosure of mistakes, and reduce expected production quotas by some pharmacies. While we acknowledge the great work that many community pharmacies are doing to improve safety, we encourage serious discussion by all about the exposed deficiencies and ongoing attention to all the challenges suggested in the 20/20 segment.

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