J. L.
I really don’t think Walgreens was…
I really don’t think Walgreens was purposely trying to harm Don—but 3 errors on 1 prescription is 3 too many!! Don takes a “Black Box” warning drug called Tykosin ( dofetilide ). A black box warning is the highest safety-related warning that medications can have assigned by the Food and Drug Administration. These warnings are intended to bring the consumer's attention to the major risks of the drug. Walgreens dispensed a drug to Don that is contraindicated with Tikosyn because it increases the blood levels of Tykosin. This drug has a narrow range between effectiveness and toxicity. Too little and it will not protect him from arrhythmias and too much will cause arrhythmias. . . #2 Problem. The instructions on the Med bottle said to “Take 1 tablet twice a day for 7 days. Dispense 10. . . It is impossible to take 2 tabs per day for 7 days when only 10 tablets are dispenses. I don’t know if this was a transcription error or a physician error—but someone should have caught it; tech or pharmacist. The pharmacy tech and the pharmacist both were complicit in this. I went to Walgreens to express my concern. The pharmacist said the tech had called the physician to check that the drug could be given with Warfarin. I asked WHY. Don has never taken Warfarin. WHY would the tech call the physician about interactions with Warfarin? Health Care in general is understaffed and overwhelmed. Chain pharmacies are evaluated on sales volume—not the safety and accuracy of what they dispense. Pharmacies have a fiduciary duty to be sure the meds dispensed are for the right person, right medication, right dose, right route (oral, IV, topical. . .) and that the Med dispensed is not contraindicated with other meds the patient takes. Don gets all his meds from Walgreens—getting all his meds from the same pharmacy is supposed to be a protection from Med interactions. I asked the pharmacist today if they were going to fill out forms that they had made a Med error. He said they would—would they if I had not asked? This is scary. This elderly former nurse who has not practiced for 25 years noticed these problems. . . I am trying to be Don’s health care advocate. . . Who is protecting other people? I have big enough ovaries (or I used to) to report and challenge errors. I told the pharmacist that I spoke with that this was a “learning opportunity” for the staff involved. The Walgreens pharmacist I spoke with today was actually very nice, concerned and said he would report the problems and the people who committed the errors would be spoken with. A sad reality is that that Walgreens’ computers sound an alarm when there is a potential medication contraindication; but staff is so busy & the alarms happen so often that the warnings are often ignored.