"In Wheaton, Illinois, a seventy-six-year-old man received an incorrectly filled, mislabeled prescription for Coumadin, a blood thinner, from a Kmart pharmacy. The pharmacist dispensed five-milligram pills instead of the two-milligram version prescribed for about one year, but marked the bottle as containing the smaller dose. The overdose caused a brain hemorrhage and jurors returned an $810,000 verdict in 1999 (1)."

Tragedies such as the one described above occur across the U.S. everyday, but because not all pharmacists are required to report their errors to their supervisors, their mistakes often go unnoticed. The Institute of Medicine found that hospital medication errors caused over 7,000 deaths and 250,000 injuries each year. In addition, each preventable adverse drug reaction adds about $5,000 to the cost of a hospital admission (2).

Because the amount of complaints continued to increase from year to year, Senators took matters into their own hands in January of 2001. After trying to find a solution for over a year, Senator Cheryl Jacques pioneered a bill that would allow state regulators to fine pharmacists up to $5,000 for their mistakes.

The bill also provides legislators with a variety of punishment options. Currently, the only way to reprimand a pharmacist is suspension of license. Because this action is often seen as extremely ruthless, it is hardly ever used. In the fiscal year 2001, the Massachusetts Board of Registration in Pharmacy resolved almost 300 cases, in which only two pharmacists' licenses were suspended and seven were placed on probation. This means that they could still work but under the assumption that their licenses would be revoked if they made another mistake. For these reasons, the proposed bill is seen as a way to significantly reduce pharmacist errors (3).

While Senators appear to have answered all the questions, the pharmacy seems to have a different opinion. Pharmacists everywhere argue that the bill will have the opposite of its proposed effects. Putting pharmacists under greater pressure will only increase the amount of errors that occur and increase the likelihood that pharmacists won't report their errors to patients because they know they will be fined.

Savita Bhatia, a registered pharmacist at Health Care Pharmacy in the south suburbs of Chicago, also disagrees with the passing of the bill. She explained, "Pharmacists don't come to work everyday hoping to give their customers the wrong medications and make them sicker than they already are. They want to help people feel better. People make mistakes, but that's just what they are, mistakes."

Customers, though, are not satisfied. When a woman from Dearborn, MI, was given Lanoxin, a heart drug, instead of Synthroid, a drug to control a thyroid condition, she became agitated and dizzy. For three months, she took the wrong drug, and dealt with a loss of appetite and balance. The mistake wasn't caught until she was admitted to the hospital. In her lawsuit, she was awarded $340,000 (1). Incidents like this enforce customer notions that something drastic should be done.

Despite some loss of patient trust, pharmacists maintain that customer awareness will prevent more of these incidences from occurring than a bill from the Senate will. The patient should be able to read the label on the bottle and understand what medication is being given. Also, patients can ask for printed information about the drug to understand how it works.

Customers should also make sure they are getting the same medication when they get refills. If the pills look different, they should ask twice to make sure they are receiving the correct medications. While the bill may count down the mistakes made in pharmacies, ultimately the patients should take responsibility of their own welfare.

Numbers for Thought

* Medication errors are estimated to kill more than 7,000 patients per year nationwide.
* Between 1983 and 1993 there was an eight-fold increase in deaths attributable to medication errors, compared to a two-fold increase in hospital deaths in the United States.
* The cost of hospital-related medication errors alone exceeds $2 billion per year. Hospital patients account for a fraction of all prescriptions filled each year.
* One study found that 4.2 percent of outpatient prescriptions result in adverse drug reactions. Pharmacies dispense over 2.5 billion prescriptions each year.

Data from pharmacy.ca.gov.

Alisha is a second-year, pre-med student double majoring in biological sciences and psychology.