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Your Doctor's Chicken Scratch Handwriting Could Kill You

Illustration for article titled Your Doctors Chicken Scratch Handwriting Could Kill You

Fifty families with unsuspecting kids in Chatham, New Jersey recently received a breast cancer drug from their local CVS instead of the fluoride pills they asked for. The kids took tamoxifen for months before anyone noticed. Outrageous, right?


Actually, it's all too common. Pharmacies across the country mix up names and prescriptions, or misread doctors famously illegible scrawl shockingly often. Just this past year, a pregnant woman with a prescription for antibiotics instead received an abortion drug. Luckily the baby wasn't aborted but now has an increased risk of health problems. A teenage boy received a leukemia drug instead of pain medication for his extracted wisdom teeth. Ouch, and also the drug could have made him sterile but luckily only shot up his blood pressure. Walgreen's paid one family $33 million for a mix up that led to a 46-year-old woman's death. Another woman was apparently psyched to accidentally receive Oxycontin and tried to keep it (she was arrested). The list goes on.


But no one knows just how long the list is because there is no list. One estimate says 7,000 people die every year due to medication errors. But no agency is specifically tasked with keeping track of these mistakes. And when pharmacies settle with victims of mix ups, they usually demand silence in exchange for cash. The FDA and the Institute for Safe Medication Practices "accept" reports about problems, but pharmacies aren't required to send reports. The U.S. Pharmacopeia also tries to keep track of mistakes but the error program is voluntary.

So since no one's looking out for you, you'd best make sure you know what kinds of pills you're swallowing. Eric Pavlack of Pavlack Law in Indianapolis writes that he's represented his fair share of mix-ups that have ended in injury and health problems. And of course personal injury lawyers are all over these cases and stand to (are) making bank. But he has some good advice for next time you pick up a prescription:

1. When your doctor gives you a prescription, be sure you can read what it says.

2. When you pick up your prescription, take the bottle out, review it, and specifically ask the pharmacist if this is the medicine and dosage that your doctor prescribed. If the pharmacist is annoyed or dismissive, it's time to find another pharmacy.

3. When you look at the bottle, verify that the medicine matches your prescription and your name is on the container. If there are any discrepancies, insist on an explanation.

4. If you experience side-effects after taking a drug that seem inconsistent with the warnings, immediately contact your doctor or pharmacist.

The FDA does try to make sure drug names aren't too similar, and they've begun rolling out bar-code systems that increase accuracy. "E-prescriptions" are also becoming more common but not nearly enough. Why on earth are doctors still writing out prescriptions by hand? Hey docs and hospitals, welcome to the 21st century, please get on board with doing it electronically.

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Unfortunately this is not a cut and dry issue. While intuition would indicate that a move to electronic systems in medicine could only be good, evidence for this has not been as solid as expected. The benefits have been minimal and the costs are very high, especially for smaller practices. Hopefully there will be more benefit as younger, more tech-savvy doctors enter practice and the systems employed by the hospitals become more user friendly, but jumping ship to EMR and eRX systems is not going to fully fix the problem. For now it's best for the doctor and patient to communicate and make sure both are on board with the plan so that someone recognizes and error if one should happen at any point in the chain. []