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2022年世界杯名单猜测

shift: prescription errors are just one more thing patients need to worry about

there were more than 100,000 medication mistakes in nova scotia over a seven-year period, with the most common errors having to do with dosage, quantity and the incorrect drug.

by lisa machado

oct 3 2022

6 minute read

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some pharmacies outsource the preparation of prescriptions

how is it that we are also expected to play the role of fact-checker when it comes to the medications our doctors order? getty

“a robot does the filling.”

i almost laughed because, well, the pharmacist was telling me that the reason there was a mistake with the prescription that i picked up for a neighbour was that a robot had filled it.

my neighbour had noticed that the dosage of his most recent prescription was a lot lower than the one he had gotten the month before — which had been double what i had picked up for him. he had just seen his doctor about a refill, but couldn’t remember if anything was said about decreasing the dose. so that morning, i called his doctor’s office to find out.

“are you sure the instructions on the bottle didn’t say to cut the tablets in half?” the clinic nurse asked. when i said no, she put me through to the doctor.

“i have a copy of the fax with the right dose. ya, they made a mistake,” the doctor said, inhaling deeply. then, “how is he feeling?”

fortunately, besides a few headaches and some nausea, my neighbour was feeling fine. but i knew — as the doctor did — that had the dose been mistakenly increased on any of his other medications, the outcome would likely have been really bad.

at the pharmacy, the pharmacist was looking at a computer, her eyes darting back and forth between the screen and the empty pill bottle i had given her as she double-checked the dosage on the label.

as the line of people grew behind me, she leaned closer to the clear plastic barrier that was attached to the counter and explained quietly that some medications are outsourced to be counted and labeled by machines — robots.

“are they double-checked?” i asked.

she nodded, adding that a pharmacist oversees the preparation of the medications and confirms the right product and dosages.

is it time to take another look at how we check prescriptions?

i had so many questions. does the pharmacist check the medications based on the doctor’s orders, or just the label? and is that why often i can’t get a prescription or a refill on the same day? and holy moly, is anyone thinking that maybe it’s time to overhaul the so-called safety checks?

“we check them here, too,” she said, not sounding too confident, “but we’re just making sure the type of medication in the bottle matches the label.” she made the motion of opening the pill bottle and looking inside.

“so you don’t check it against the doctor’s orders,” i said.

“umm, no.”

while she was very nice and empathetic and apologetic, asking how my neighbour was doing and promising to log the error — she even suggested that i always check with the doctor if there are doubts about a medication — i was deeply annoyed and concerned. after all, there are a lot of things patients should be able to count on unfailingly — a bed in an emergency department, a doctor who listens and acts on their worries and concerns, and yup, getting the right dose of the right drug.

there are already so many things that are on us to take care of and oversee — often when we are sick, tired and stressed — like keeping track of tests and other health records, figuring out how to pay for expensive treatments and staying up-to-date on research and treatments so we know to ask about options. so how is it that we are also expected to play the role of fact-checker when it comes to the medications our doctors order?

as it turned out, a few minutes later, as i sat with my neighbour telling him about the sloppy robots — which he thought was a little funny — the pharmacist called to tell me that she gave me the wrong information. that in fact, the pills had not been counted by a robot, but rather, a real-life human being had done the counting and the labeling and had also made the mistake.

“she’ll be spoken to,” she said.

my neighbour seemed satisfied with the promise of discipline, but i was keenly aware that a simple reprimand wouldn’t have been much comfort to anyone if he had gotten really sick — or worse. then he would have become just one more medication error statistic — something that, according to an investigative report by cbc marketplace, no one is keeping track of.

in fact, although the cbc report uncovered many stories of prescription errors across canada, some with grave consequences, it noted that — with the exception of nova scotia — no provinces officially track mistakes. and if this province’s numbers are any indication — almost 100,000 medication mistakes in 2018 over seven years according to a cmaj study — patients should probably be paying more attention and asking more questions before leaving a pharmacy with medication in-hand. the most common mistakes — or “quality-related events”? “incorrect dose or frequency, incorrect quantity and incorrect drug,” wrote the study authors.

and while there are no definitive national numbers on mistakes by pharmacies, the institute for safe medication practices canada, an independent non-profit, is one body that’s focused on improving medication safety. in addition to information like what questions canadians should ask about their medications, ismp canada also allows people to report a medication error.

my neighbour and i talked for awhile about whether or not he wanted to file a report, but also about the idea of outsourcing the putting together of medications to machinery. although this wasn’t the reason behind the mistake with his prescription, according to the pharmacist, it was something that neither of us had even considered.

i asked everyone i knew if they had ever heard of such a thing. and while the answer was always no, it was worrying how many shared their own stories of medication mistakes — from incorrect doses and the wrong instructions on how to take the drug to getting the wrong drug entirely. even when i asked the very informed healthing team if they had ever heard of outsourced pill-counting, i got nothing, although one editor said she wasn’t surprised. after all, she pointed out, it wouldn’t make sense for just one pharmacist and a few staff members to be expected to tally and inspect the hundreds of prescriptions they receive to be filled every week on their own. fair enough.

some pharmacies outsource the filling of prescriptions

when i reached out to the corporate office of the company that owns the pharmacy, the involvement of robots was not confirmed directly, but the outsourcing was.

“we can confirm that, in accordance with the ontario college of pharmacists’ centralized prescription processing (central fill) policy, some of our locations utilize an affiliated central fill pharmacy to process prescriptions,” the company’s pr team wrote in an email. “prescriptions are provided to patients at their local pharmacy.”

the central fill policy has all the guidelines you would expect and want if you are someone who depends on a pharmacy for medication — things like maintaining standards of practice and complying with the code of ethics, as well as ensuring accurate labeling, the security of patient information and the ability to track prescription orders. it was clear that the ability to know whether or not a prescription was prepared at a central fill pharmacy was also critical.

a website under the heading, “helpful links,” took me to pharmacyconnection.ca, an ontario college of pharmacists publication, that listed five things to know about working with a central fill pharmacy — one of which was that a patient has to consent to having their medication processed by the central fill pharmacy, as well as be aware that there will be “a transfer of health information.”

and while i myself have never provided consent that i know of, i am now interested to know the deets: where are my prescriptions processed, and if off-site, is it really done by a robot? and have i consented to have my personal health information shared? these will be just some of my questions for the pharmacist the next time i see her.

but only after i check the dosage, make sure the medication is the right one and confirm that everything matches my doctor’s instructions.

lisa machado is the executive producer of healthing.ca.

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lisa machado

lisa machado began her journalism career as a financial reporter with investor's digest and then rogers media. after a few years editing and writing for a financial magazine, she tried her hand at custom publishing and then left to launch a canadian women's magazine with a colleague. after being diagnosed with a rare blood cancer, lisa founded the canadian cml network and shifted her focus to healthcare advocacy and education.

shift: prescription errors are just one more thing patients need to worry about

there were more than 100,000 medication mistakes in nova scotia over a seven-year period, with the most common errors having to do with dosage, quantity and the incorrect drug.

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is it time to take another look at how we check prescriptions?

some pharmacies outsource the filling of prescriptions

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shift: prescription errors are just one more thing patients need to worry about

there were more than 100,000 medication mistakes in nova scotia over a seven-year period, with the most common errors having to do with dosage, quantity and the incorrect drug.

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is it time to take another look at how we check prescriptions?

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some pharmacies outsource the filling of prescriptions

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