Drug Injury Watch

Prescription Drug Medication Errors Can Be Prevented By Taking Some Common Sense Precautions

Ten Strategies Intended For Pharmacists Can Help Patients Stay Safe, Also

(Posted by Tom Lamb at DrugInjuryWatch.com)

It is relatively well-accepted in the healthcare community that medication errors involving prescription drugs happen more often than they should but the incident rate could be reduced if both pharmacists and patients took certain precautions.

The following set of precautions, from the an article "Pharmacy Dispensing Mistakes: 10 Strategies for Minimizing Dispensing Errors" that was published online by Pharmacy Times a couple of years ago, is intended for pharmacists but includes some points that can be helpful to patients.

Before we get to the list of ten ways that pharmacists might reduce the risk of causing or contributing to medication errors, here is some background about the problem generally from this Pharmacy Times article:

Dispensing errors include any inconsistencies or deviations from the prescription order, such as dispensing the incorrect drug, dose, dosage form, wrong quantity, or inappropriate, incorrect, or inadequate labeling. Also, confusing or inadequate directions for use, incorrect or inappropriate preparation, packaging, or storage of medication prior to dispensing are considered to be errors. Errors occur at a rate of 4 per day in a pharmacy filling 250 prescriptions daily, which amounts to an estimated 51.5 million errors out of 3 billion prescriptions filled annually nationwide.  [footnotes omitted]

Now, here is the list of strategies for pharmacists to adopt in order to reduce the risk of causing a patient possible harm by means of a medication error:

1. Ensure correct entry of the prescription.

2. Confirm that the prescription is correct and complete.

3. Beware of look-alike, soundalike drugs.

4. Be careful with zeros and abbreviations.

5. Organize the workplace.

6. Reduce distraction when possible.

7. Focus on reducing stress and balancing heavy workloads.

8. Take the time to store drugs properly.

9. Thoroughly check all prescriptions.

10. Always provide thorough patient counseling.

This last point is especially important and, for the reasons set forth below, it is unfortunate that many patients are in too much of a hurry to take advantage of this service which is routinely offered and declined daily in pharmacies large and small.

Approximately 83% of errors are discovered during counseling and are corrected before the patient leaves the pharmacy. Therefore, it is important to go beyond offering to counsel and provide counseling for each patient. It is considered good practice to open the container and show the actual medication to the patient during counseling rather than deliver it to the patient in a sealed bag. Completing this process will provide an opportunity for the patient to see the medication and ask questions if it looks different from what he or she has been taking. Counseling should also include the instructions on how to take the medication and appropriate route of administration. Many dispensing errors are attributed to misunderstood directions for use. Educating patients about safe and effective use of their medication promotes patient involvement in their health care, which will likely reduce medication errors.  [footnotes omitted]

In closing -- and this is the real take-away point for patients as regards the above list of prescription drug safety strategies -- while it may take a few more moments before leaving the pharmacy, one should always take advantage of the pharmacist-patient counseling session as the best final precaution for preventing possible harm from medication errors.

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National Alert Network For Serious Medication Errors: New Drug-Safety Project From ISMP And ASHP

Will Send Email Alerts To Healthcare Providers When Dangerous Or Life-Threatening Prescription Drug Errors Are Reported To ISMP

(Posted by Tom Lamb at DrugInjuryWatch.com)

A January 19, 2010 article, "Catching Deadly Drug Mistakes", by The Wall Street Journal's health reporter, Laura Landro, brought to our attention a new project intended to reduce medication errors. 

From that WSJ article:

... Medication errors cause at least one death every day and injure approximately 1.3 million people annually in the United States, according to the Food and Drug Administration. Now, new efforts are underway to quickly spread the word about such errors and offer guidance on how to prevent similar mistakes.

The non-profit Institute for Safe Medication Practices [(ISMP)], which is certified by the federal government to collect error reports and other information about quality breaches, and the American Society of Health-System Pharmacists [(ASHP)]are launching a new National Alert Network for Serious Medication Errors. The network, which was unveiled last month, will be used to send email alerts to 35,000 pharmacists working in hospitals and health systems, as well as physicians and nurses, when a dangerous or life-threatening error is reported to ISMP....  The hope is that widely spreading the word about such errors will cause doctors and pharmacists to be more cautious—and ultimately prevent future mix-ups. Relevant alerts will also be sent to 20,000 drugstore pharmacists.

Hopefully this new National Alert Network for Serious Medication Errors will advance the cause of making medications safer for patients.

In her January 19 article, WSJ health reporter Landro also reminds us about two very good resources that are available to consumers and patients:

ConsumerMedSafety.org: A portal of information provided by the Institute for Safe Medication Practices (ISMP) where consumers can sign up for customized alerts about the medications they take and report problems they encounter with medications; and,

MedWatch: The U.S. Food and Drug Administration (FDA) site for safety information on prescription drugs and other medical products, where patients can submit reports of medication errors and other serious adverse reactions directly to the FDA.

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DrugInjuryLaw.com: Legal Information And News About Prescription Drug Side Effects

Consumers Union’s Safe Patient Project Forum Webcast: “To Err Is Human, To Delay Is Deadly”

Marks 10th Anniversary Of IOM Study On Medical Errors And Raises Concerns About Lack Of Progress

(Posted by Tom Lamb at DrugInjuryWatch.com)

The Consumers Union’s Safe Patient Project (formerly Stop Hospital Infections) is holding a forum, “To Err Is Human, To Delay Is Deadly,” in Washington, DC, today, Tuesday, November 17, 2009, from 10 a.m. to 3:30 p.m. EST. 

There is a free live webcast on this “To Err Is Human, To Delay Is Deadly” forum on the day of the event.  If you cannot tune in then, a recording of this forum webcast will be available up to a year after this date.

The forum marks the 10th anniversary of the IOM study on medical errors and raises concerns about the lack of progress over the past decade in preventing medical harm.  Speakers at this forum include:

Arthur Levin, Center for Medical Consumers, member of the original IOM committee and long-time consumer advocate for patient safety;
 
Dr. Richard Shannon, University of Pennsylvania Health System, successful advocate for patient safety from within the walls of the hospital, challenging those in the medical community who say it is too difficult to stop hospital-acquired infections;

Merrill Goozner, independent author, writer and active blogger on health issues, former director of the Integrity in Science project at the Center for Science in the Public Interest, who will speak about conflicts of interest and the influence of the medical industry on creating a safer and more patient oriented health care system; and,

U.S. Representative Bruce Braley of Iowa, a strong advocate for eliminating medical harm to save patients’ lives and to reduce costs to the health care system.

The Safe Patient Project campaign released a report earlier this year on the subject, which describes how this campaign covers the following issues:

• hospital-acquired infections
• medical errors and other medical harm
• physician accountability
• drug safety

We encourage those who are interested in medication mistakes and medical errors to take the time to view this “To Err Is Human, To Delay Is Deadly” forum webcast either live, today, or at your convenience in the weeks or months to come.  Of course, you should feel free to share this forum webcast information with others, also.

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DrugInjuryLaw.com: Legal Information And News About Prescription Drug Side Effects

What Are Medication Errors And How Do These Medical Mistakes Tend To Happen

North Carolina State Board Leads Way As Regards Reporting Of Pharmacy-Associated Medication Mistakes

(Posted by Tom Lamb at DrugInjuryWatch.com)

QJM is a long-established, leading general medical journal. It focuses on internal medicine and publishes peer-reviewed articles which promote medical science and practice.

In the August 2009 edition of QJM is an article, "Medication errors: what they are, how they happen, and how to avoid them", which provides a good overview of the various aspects of a medication mistake.  Here are some fundamental points from the Abstract for this recent medical journal article:

• A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient.

• Medication errors can occur in

-- deciding which medicine and dosage regimen to use (prescribing faults—irrational, inappropriate, and ineffective prescribing, underprescribing, overprescribing); writing the prescription (prescription errors);

-- manufacturing the formulation (wrong strength, contaminants or adulterants, wrong or misleading packaging);

-- dispensing the formulation (wrong drug, wrong formulation, wrong label);

-- administering or taking the medicine (wrong dose, wrong route, wrong frequency, wrong duration);

-- monitoring therapy (failing to alter therapy when required, erroneous alteration). 

[Note: Format of sentence was changed for easier reading.]

• [Medication errors] can be classified, using a psychological classification of errors, as knowledge-, rule-, action- and memory-based errors.

• Errors in prescribing include irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing (collectively called prescribing faults) and errors in writing the prescription (including illegibility).

Remarkable to me, at least, is that only one state, North Carolina, has a mandatory reporting requirement for medication errors that involve a pharmacist or pharmacy.

According to "What state boards are doing about medication errors", an online special article published July 1, 2009 by Drug Topics ("The Newsmagazine for Pharmacists"):

As of June 2009 it appears that North Carolina remains the only state that requires any consistent public reporting of pharmacy-associated medication errors. In North Carolina, pharmacists must report errors associated with deaths.

According to Jay Campbell, RPh, JD, executive director of the N.C. Board of Pharmacy in Chapel Hill, “The requirement is that one needs to report [an error] to the board of pharmacy if they have reason to believe that a dispensed drug caused or contributed to a death of a patient. It is not a mandatory reporting of serious errors, only a report of deaths. Some of the data [we gather] are made public, and some aren’t. We produce a spreadsheet of information and we scrub out certain things that are not public information,” he said.

Campbell explained to Drug Topics that the “reporting rule isn’t keyed to an error; it’s broader than that. [We require a report] even if a drug is dispensed as ordered, yet it contributed to a death. Sometimes there’s a need to investigate — especially in a hospital, where a patient may have come in with underlying problems. There does sometimes seem to be a temporal relationship.”

This Drug Topics article adds that the North Carolina state board receives on average 40 to 60 reports per year, and, according to Campbell:

In our experience, we have seen a disproportionate number of deaths with anticoagulant products. They are a tiny fraction of global dispensing, yet they have, over the years, represented about 20 percent of reports.

Previous Drug Injury Watch articles about this subject area can be found in the Medication Errors category archives.

A Summary Of Inpatient Cardiovascular Medication Error Reports Involving Children

July 2009 Pediatrics Medical Journal Article Finds Most Cases Involved Infants Less Than One Year Of Age

(Posted by Tom Lamb at DrugInjuryWatch.com)

The article "Cardiovascular Medication Errors in Children" was published in the July 2009 edition of the medical journal Pediatrics.

The authors of this article had two basic aims: (1) to describe pediatric cardiovascular medication errors; and, (2) to determine patients and medications with more-frequently reported and/or more-harmful errors.

For their research, the authors analyzed cardiovascular medication error reports from the US Pharmacopeia MEDMARX database from 2003–2004 for patients no older than 18 years of age.

From the Abstract for this July 2009 Pediatrics article we get their findings:

RESULTS:  A total of 147 facilities submitted 821 reports with community hospitals predominating (70%). Mean patient age was 4 years (median: 0.9 years). The most common error locations were NICUs, general care units, PICUs, pediatric units, and inpatient pharmacies. Drug administration, particularly improper dosing, was implicated most commonly. Severity analysis showed 5% "near misses," 91% errors without harm, and 4% harmful errors, with no reported fatalities. A total of 893 medications were cited in 821 reports. Diuretics were cited most frequently, followed by antihypertensives, angiotensin inhibitors, β-adrenergic receptor blockers, digoxin, and calcium channel blockers. Calcium channel blockers, phosphodiesterase inhibitors, antiarrhythmics, and digoxin had the largest proportions of harmful events, although the values were not statistically significantly different from those for other drug classes. Infants <1 year of age accounted for 50% of reports. Proportions of harmful events did not differ according to age.

It turned out that most of the errors found by these researchers were due to improper dosing during administration of a cardiovascular medication.  Hopefully, as hospitals continue to improve their drug-delivery systems, this type of medical error will become less and less frequent in the future.

If this topic interests you, perhaps you want to take a look at our collection of past articles concerning various aspects of medication errors.

Medication Errors Are One Of The Most Common Medical Mistakes, But Number Can Be Reduced

Two Reports From April 2009 Medical Journal Offer Possible Solutions To A Problem Which Affects At Least 1.5 Million People Per Year

(Posted by Tom Lamb at DrugInjuryWatch.com)

The April 27, 2009 edition of the Archives of Internal Medicine included two articles by researchers who have suggested some ways by which hospitals and pharmacists could work to reduce the high annual number of medication errors in the U.S.

These two medical journal articles are:

1. "Effect of a Pharmacist on Adverse Drug Events and Medication Errors in Outpatients With Cardiovascular Disease" (Arch Intern Med. 2009;169(8):757-763); and,
2. "Effect of an Electronic Medication Reconciliation Application and Process Redesign on Potential Adverse Drug Events: A Cluster-Randomized Trial" (Arch Intern Med. 2009;169(8):771-780).

For more about these two articles we turn to an April 27, 2009 HealthDay News report, "Medication Errors Could Be Cut: Experts", which was published on the MedlinePlus web site (note: site had once stated "this news item will not be available after 07/26/09"):

In the first report, researchers led by Dr. Jeffrey L. Schnipper, of Brigham and Women's Hospital and Harvard Medical School, used a computer system to keep track of the medications patients were taking when they were admitted to the hospital and the medications they were taking when they were discharged.

"It turns out that we commit about 1.5 errors per patient either for the admissions orders in the hospital or, much more commonly, in the discharge orders, which is kind of appalling," Schnipper said. "These are errors with potential for patient harm. There are about three times as many errors without potential for patient harm."...

The problem of medication error starts when patients are asked what drug they are taking when they come into the hospital, Schnipper said. "Patients don't know what they are taking. You have got to carry your current accurate medication list in your wallet," he advised....

In a second report, a team led by Michael D. Murray, chair of the department of pharmaceutical policy and evaluative sciences at the University of North Carolina at Chapel Hill, found that among outpatients with high blood pressure, when pharmacists, doctors and patients communicate, medication errors decrease.

"By working closely with doctors and nurses, pharmacists can help people avoid problems with their medication for chronic diseases like high blood pressure and heart failure," Murray said. "This has favorable effects on health and health-care costs."...

"This study shows the importance of having a pharmacist actively involved in asking about how the patient is doing, what type of side effects is the patient having, and is the patients taking the medication," Grissinger said. "That is as important as the initial consultation."

We have reported previously about the various aspects of medication errors and what might be done in terms of prevention.  We are encouraged by these two recent medical journal articles that progress can and will be made in reducing the high number of these medical mistakes involving patients in the U.S. healthcare system.

Beware The Potential Dangers Of Free Drug Samples

Some Ways That Free Drug Samples Can Harm Patients

(Posted by Tom Lamb at DrugInjuryWatch.com)

PLoS Medicine-- which is a peer-reviewed open-access journal published by the Public Library of Science -- published an essay by Susan Chimonas and Jerome P. Kassirer in May 2009 called "No More Free Drug Samples?" which provides a fresh perspective on a well-established practice in doctors office across the U.S.

This essay starts with the ideas that many of us may have about this practice:

Everybody likes something free, and free prescription drug samples are no exception. Patients love to receive them, and doctors feel good about handing them out. The practice of providing free drug samples is based on the tacit assumption that “sampling” does much more good than harm.

Chimonas and Kassirer go on from there to deconstruct these preconceptions, working at various levels:

In this essay, we question the assumption that good trumps harm when prescription drugs are provided free to practicing doctors. We argue that “sampling” is not effective in improving drug access for the indigent, does not promote rational drug use, and raises the cost of care.

I want to focus on the drug-safety aspect of this free drug samples issue. 

In their May 2009 PLos Medicine essay, Chimonas and Kassirer make these points in support of their contention that samples can have "negative consequences" when it comes to patient-health:

• In drugstores, pharmacists often identify potentially harmful drug interactions, intercept inadvertent medication errors, and offer a patient-friendly printout of instructions. In doctors' offices, however, detailed patient education regarding sample use rarely occurs, and when it does, it usually lacks information about drug interactions or instructions on how the drug should be taken. [footnote omitted]

• Moreover, if distribution is inadequately documented in patients' records, some people who receive samples in doctors' offices may not be notified or told to discontinue the medication in the event of a product recall or the emergence of new drug complications.

• The samples that drug representatives offer are almost never time-worn and well-tested drugs, nearly never generics, and usually comprise the newest agents on the market. As such, they expose patients to risks not yet identified in clinical trials. The experience with Vioxx is a case in point.

Chimonas and Kassirer discuss in this insightful essay, also, several other concerns they have with the seemingly "generous" practice of doctors dispensing free drug samples to patients.  It total, the authors conclude that:

The tradition of physicians dispensing samples has many serious disadvantages and is as anachronistic as bloodletting and high colonic irrigations. As the profession begins to slowly extract itself from the influential grip of industry, it must also deal with the undue influence of free samples.

If this topic interests you, "No More Free Drug Samples?" is a relatively short essay that is worth reading when you have an opportunity.

Adverse Drug Reactions Lead To Significant Number Of ER Visits Each Year

New Canadian Study Highlights Link Between Some Medications And Serious Health Problems

(Posted by Tom Lamb at DrugInjuryWatch.com)

A June 3, 2008 article, "More than 1 in 9 ER visits medication-related", in The Globe and Mail reported the highlights of a study published in June 2008 by the Canadian Medical Association Journal which concerned 1,017 patients who presented at the Vancouver General Hospital emergency room (ER) during a 12-week period back in 2006.

The team of researchers who conducted this study were led by Peter Zed, an associate professor at Dalhousie University and the clinical coordinator in emergency medicine at Capital Health in Halifax.

From the June 3 Globe and Mail news article we get these study-findings about adverse drug reactions (ADRs) in Canada:

• 12 per cent, or more than 1 in 9, of all emergency room visits were medication-related, ranging from patients who did not take their medication as prescribed to those who had a bad reaction to a drug;

• adverse drug reactions accounted for nearly 40 per cent of those visits, making them the most common medication-related problem that landed patients in the emergency room;

• 60 per cent of those visits were unpreventable - meaning that patients experienced problems after taking the medication as directed;

• many of the adverse drug reactions in the study involved patients who experienced bleeding complications, rashes or other issues that required hospitalization in some cases; 

• non-adherence - when patients don't take medication as directed - was responsible for about 30 per cent of medication-related emergency room visits;

• some patients may be on several different kinds of medication, which can greatly increase the risk of drug-related health problems;

• the most common drug categories associated with problems were antimicrobial agents, which include antibiotics, painkillers containing opioids and anti-psychotic drugs; and,

• over all, about 75 per cent of the medication-related problems documented in the study were considered moderate, 10 per cent severe and about 15 per cent mild. Some of the most common issues were pain, delusion, paranoia and hallucinations, as well as vomiting and other gastrointestinal problems.

In 2006 we ran a four-part series on adverse drug reactions (ADRs) in the U.S., which started with this post, "Extent Of Serious Adverse Drug Reactions In The U.S. (Part of Series: ADRs in US)".

To reiterate what I said in my prior post, we encourage doctors and patients, both, to submit MedWatchreports about ADRs to the agency when appropriate.

June 2008 FDA Meeting Will Address Problem Of Look-alike And Sound-alike Drug Names

Confusion Between Similar Drugs Is A Cause Of Medication Errors That Agency Will Focus On In New Pilot Program

(Posted by Tom Lamb at DrugInjuryWatch.com)

To start, we get this background information from "Medication Errors: FDA 101", which was posted March 14, 2008 on the FDA's web site:

A medication error is any preventable event that may cause or lead to inappropriate medication use or harm to a patient. Since 2000, the Food and Drug Administration (FDA) has received more than 95,000 reports of medication errors. FDA reviews reports that come to MedWatch, the agency's adverse event reporting program.

"These reports are voluntary, so the number of actual medication errors is believed to be higher," says Carol Holquist, R.Ph., Director of the Division of Medication Error Prevention in FDA's Center for Drug Evaluation and Research.

FDA works with many partners to track medication errors, including the U.S. Pharmacopeia (USP) and the Institute for Safe Medication Practices (ISMP). "Every report received through the USP/ISMP Voluntary Medication Error Reporting Program (MERP) automatically gets sent to FDA's MedWatch program," says Mike Cohen, R.Ph., Sc.D., President of ISMP. "It takes a cooperative approach to monitor errors, evaluate them, and educate the public about strategies to keep errors from happening again."

Medication errors occur for a variety of reasons. For example, miscommunication of drug orders can involve poor handwriting, confusion between drugs with similar names, poor packaging design, and confusion of metric or other dosing units.

On June 5-6, 2008 the FDA will be convening a public meeting to address the miscommunication problems and confusion the can be caused by look-alike or sound-alike drug names.  In late May the agency released a 29-page draft concept paper that will be used as a guide for discussions during the two-day meeting.

For more about the June 2008 FDA public meeting and this draft concept paper, we look to the May 29, 2008 edition of FDAnews Drug Daily Bulletin, published by Washington Business Information, Inc. / FDAnews:

Reducing medication errors caused by look-alike and sound-alike proprietary names — through a two-year pilot program it expects to begin in 2009 — is the focus of a draft concept paper the FDA has released in advance of a public meeting scheduled for June 5–6.

 The pilot program will be designed to let drug companies volunteer to evaluate proposed proprietary names and submit the data for review to CDER or CBER, as appropriate....

In the pilot program, CDER and CBER will evaluate the safety and promotional implications of submitted drug names. If a name seems prone to cause confusion, the relevant center “will not recommend its approval for use in the market and will request the applicant propose an alternate name for evaluation,” the draft says. “Any preventable risk of error that can be identified prior to drug approval should be addressed.”

Returning to the FDA document we started with for background, it provides these links for those who want more information about medication errors and mistakes:

6 Tips to Avoid Medication Mistakes
www.fda.gov/consumer/updates/medtips062107.html

Medication Errors (FDA)
www.fda.gov/cder/drug/MedErrors/default.htm

Reporting Adverse Experiences to FDA
www.fda.gov/medwatch/how.htm

Institute for Safe Medication Practices
www.ismp.org

U.S. Pharmacopeia
www.usp.org

To assist the FDA with keeping track of adverse drug events, we encourage doctors and patients, both, to submit MedWatch reports to the agency when appropriate.

Medication Mistakes And Pharmacy Errors Continue To Be A Large Problem

Prescription Drugs Wrongly Prescribed Or Improperly Dispensed Are Preventable Adverse Events Which Need To Be Reduced In Number -- And This Can Be Done

(Posted by Tom Lamb at DrugInjuryWatch.com)

In a February 14, 2008 article, "1 in 10 patients gets drug error", Boston Globe reporter Patricia Wen presented some disturbing data from a study which examined adverse events involving prescription errors that occurred in six undisclosed Massachusetts community hospitals:

One in every 10 patients admitted to six Massachusetts community hospitals suffered serious and avoidable medication mistakes, according to a report being released today by two nonprofit groups that are urging all hospitals in the state to install a computerized prescription ordering system.

The report is the first large-scale study of preventable prescription errors in community hospitals, and its author, Dr. David Bates of Brigham and Women's Hospital in Boston, said he was surprised that these mistakes were so frequent in these community hospitals....

The researchers reviewed a total of 4,200 randomly selected patient medical charts at the six community hospitals, covering stays from January 2005 to August 2006. An average of 10.4 percent of patients suffered a preventable "adverse drug event" - defined as a case in which the patient was given a drug even though the medical records noted that the medication could trigger a drug allergy or that the dose given would exacerbate a medical condition. Medication errors were counted only when patients suffered serious reactions, including going into shock or suffering kidney failure. In nearly every instance, the patients remained in the hospital longer to recover from the mistake. Nobody died from any of the mistakes, researchers said.

This February 14 article in the Globe goes on to describe how the computerized prescription ordering system mentioned above works, as well as what types of results its use can produce:

[T]e computerized physician order entry system, which requires doctors to type into a central database every medical order, including prescriptions, diagnostic tests, and blood work. The doctors' orders are matched against the patient's medical history, triggering red flags to prevent problems related to drug allergies, overdoses, and dangerous interactions with other drugs.

Bates said that after this system was put in place at Brigham and Women's Hospital in 1995, preventable medication errors declined by 55 percent over the next two years....

Ms. Wen includes in her article various discussions about how medical insurers, government officials, and healthcare providers, all, would benefit from the computerized system being used at more hospitals in Massachusetts and across the nation.

Turning to another aspect of medication errors, on February 12, 2008 the Indianapolis Star published a lengthy USA Today article, "Too many prescriptions, too few pharmacies", which reported the results of an investigation that USA Today conducted:

The investigation reviewed policies and alleged errors at rivals Walgreens and CVS, the nation's two largest drugstore chains, which fill nearly one-third of all retail prescriptions nationwide. It included a review of scores of lawsuits, as well as pharmacy board disciplinary actions in 10 states and interviews with pharmacists, drug-error victims, their families and attorneys. Some common factors emerged:

• Too many prescriptions, too few pharmacists....
• An emphasis on speed....
• A reliance on technicians....
• Pharmacist incentive awards....
• Counseling gaps....

We learned from this February 2008 USA Today article about prescriptions being improperly filled by pharmacists that, remarkably, the North Carolina Board of Pharmacy is the only state board that requires all major drug errors to be reported to the agency.

The online version of this USA Today article has an interactive graphic component, "How prescriptions are filled and where errors can occur", which gives one a better idea about what goes on behind the counter at your typical chain-store pharmacy.

For anyone interested in the causes and effects of medication errors, both of these February 2008 news reports are well worth your time.