Pharmacy board documents hundreds of pharmacist errors

Pharmacy board documents hundreds of pharmacist errors


by STUART WATSON / NewsChannel 36

Bio | Email | Follow: @stuartwcnc

Posted on May 3, 2011 at 11:15 PM

Updated Wednesday, May 4 at 8:01 AM

CHARLOTTE, N.C. -- You go to the pharmacist to get medicine to get healthy but a mistake at the drugstore can make you sicker. In extreme cases, the wrong drug or the wrong dose can even kill you.

Pharmacists and technicians in North Carolina have made more than 400 such mistakes in the last five years, according to a NewsChannel 36 I-Team review of data from the NC Board of Pharmacy. In more than half those errors, the pharmacy substituted the wrong medication.

The I-Team’s analysis of pharmacy errors was prompted by a complaint from a Charlotte woman who accidentally overdosed her daughter when the pharmacy printed the wrong dosage on her medication’s label.

Nine-year-old Shelby Alicea is a healthy, happy elementary student now, working on homework on her front steps after school. But her mother, Melissa Fink, got a real scare earlier this year. That’s when a pharmacist or technician at the Rite Aid pharmacy on Idlewild at W.T. Harris Boulevard typed the wrong dosage on the prescription.

Shelby had an ear infection. Her doctor prescribed Amoxicillin, a common bubble-gum pink liquid antibiotic. The prescription in her medical record told her to take 7 ½ milliliters twice daily. But the label on the bottle printed by the pharmacy reads 7 ½ TEASPOONS twice daily – much more.

Fink didn’t catch the mistake until she had almost drained the bottle in less than three days.

“It scared me,” she said.

The mistake made Shelby even sicker. Fink said her daughter had vomiting and diarrhea.

“Y’know, I trusted the pharmacy,” said Fink. “I want something done to the pharmacist because they acted like it was no big deal.”

“We take every complaint like this one very seriously,” said Rite Aid spokeswoman Ashley Flower. “Our pharmacy staff apologized and the district manager visited the store and retrained the staff.”

Flower says Rite Aid took “appropriate action” with the employee but said she could not reveal what that action was.

“When there’s an error and it happens to you it’s a big deal,” said Dr. Greg Alston, an Assistant Dean and Professor of Pharmacy at Wingate University. He has practiced pharmacy at a chain drug store and an independent.

“When you make a mistake as a pharmacist you're upset and defensive,” said Alston. “If you're defensive at that point it escalates into a bigger battle.”

The North Carolina Board of Pharmacy investigates complaints of errors.

The NewsChannel 36 I-Team analyzed a spread sheet of five years worth of those errors – from 2006 through 2010. The most common errors in pharmacies are NOT mislabeling – the most common error is the substitution of the wrong drug, which happened 226 times in the last five years accounting for more than half the documented errors.

Other errors include wrong dosage, wrong directions, wrong patient, (one patient’s drugs given to a different patient), and the wrong count or number of pills or tablets in the bottle. (See chart below.)

North Carolina Pharmacy Errors: 2006 -2010
Wrong meds: 226
Wrong dose: 80
Wrong directions: 77
Wrong patient: 24
Wrong count: 12
Dr. Alston says he doesn’t blame patients but the numbers mean patients and parents should be wary. “If there's anything that doesn't look right you should call and ask,” he said. 

It’s a lesson Melissa Fink learned the hard way – to check the prescription at the cash register before leaving the store.

If you think your pharmacy has made a mistake, you can file a complaint with the NC Board of Pharmacy by calling (919) 246-1050 or logging on to and clicking on the “File a Complaint” button in the middle of the left-hand margin or by e-mailing