Adle Joseph loves being a small-town pharmacist, and he's been one for 37 years. He knows many of his customers by name and by face, and today he fills prescriptions for children whose parents played Little League baseball on teams that he coached in the 1970s and '80s. For Joseph, a stroll through his hometown of Leesburg, Va., means greeting the customers who are also his friends and neighbors.
"They call me at home to ask questions. I don't mind," he says. "I know a lot of my patients. I know their problems, if they've been in the hospital or not. You have to know your people and they have to know you care."
But things have changed a lot since he started in the business in the 1960s. In those days, there were fewer prescription drugs on the market and few had health insurance that covered them. Prescription drugs weren't advertised on television and managed care didn't exist. Back then, pharmacists and doctors were highly trusted and customers didn't ask many questions. "There was no insurance; everything was cash," Joseph remembers. It was, to be sure, a simpler time.
Today, Joseph says, the pressure on pharmacists is greater than it's ever been. "Everything is more time consuming. The phone is constantly ringing, you're making calls to patients and doctors, you're trying to deal with insurance. The conditions are horrendous at times."
Joseph's experience is shared by pharmacists across the country. The number of prescriptions has doubled in the past decade, from 1.5 billion in 1989 to a projected 3 billion this year, according to the National Association of Chain Drug Stores. But the number of pharmacists has not kept pace; the association estimates the nationwide shortage at more than 7,000 pharmacists. At the same time, managed care requirements have further increased the workload on pharmacists, who find themselves overwhelmed.
The result is an increasingly dangerous situation in our nation's pharmacies. Although most states do not require drugstores to report mistakes, serious medication errors are on the rise. A Feb. 28, 1998, study in the medical journal the Lancet estimated that in a 10-year period starting in 1983, the number of deaths caused by drug errors jumped 250%, reaching more than 7,000 a year by 1993, the last year for which data are available. According to the FDA, an estimated 1.3 million Americans are injured each year from medication mistakes. For some people, these errors have tragic consequences.
Heartrending Errors
Bryn Cabanillas was just 6 years old when her parents picked up a prescription for an antiseizure medication at a Thrifty Payless drug store in Costa Mesa, Calif. The order was mistakenly filled at nearly seven times the correct dosage, leaving Bryn with serious brain damage, unable to speak or get out of bed. In 1998, a California jury ordered Thrifty to pay damages of $30.6 million to her family.
Another tragic error took place earlier this year. On April 4, Kellie Ward walked into Leesburg Pharmacy in Virginia to drop off a prescription for her son. Five-year-old Brendan had been wetting his bed since his parents separated four months earlier. The family's pediatrician suggested they try an antidepressant, imipramine, commonly used to help children with the problem. The doctor wrote a prescription for the drug at a concentration of 50 milligrams per teaspoon.
Kellie picked up the medication from the drug store and gave Brendan two teaspoons of the syrup before tucking him into bed. At 7 a.m. the next morning, she came in and found her son dead.
Brendan died of an imipramine overdose because of a simple error. Instead of entering into the pharmacy computer the correct dose of 50 milligrams per teaspoon, a Leesburg Pharmacy technician added an extra digit and then filled the prescription. Before a pharmacist could check it for accuracy, a clerk sold the bottle to Kellie Ward. It contained imipramine at a concentration of 250 milligrams per teaspoon -- five times the correct dosage.
For Adle Joseph, the tragedy at Leesburg Pharmacy was ironic. He went to work there in 1998, leaving his previous employer of 35 years because he wanted to work in a saner -- and safer -- drug store. He had been happy enough for most of his tenure, but in 1987 a national chain bought the regional pharmacy he'd been working for. Within two years, Joseph says, store clerks had their hours slashed and the pressure on pharmacists mounted. The pharmacy counter was open from 9 am to 9 pm, with only one pharmacist to staff it.
"The pharmacist was there almost exclusively by himself," Joseph says. "We would work 12-hour days, and it was difficult to even go to the bathroom. A lunch break was unheard of. Nobody can tell me that after an eight- or nine-hour shift, you don't start to get tired. And if you're working all day by yourself, it increases the chance of error hugely."
Today, Joseph says, his hours are a little better and he feels the operation is somewhat safer. But even at the safest pharmacy, errors can occur, as Joseph and his colleagues learned last year.
More Drugs, More Ads on TV
There are several reasons for the staggering increase in prescription use. New drugs are hitting the market at a record pace. To keep costs down, many conditions that were once treated in hospitals are now handled on an outpatient basis, requiring complex drug regimens. Also, a rapidly growing older population is using more drugs, and advertising campaigns on television and radio have increased awareness and demand for certain medications. And then there's managed care, which has burdened pharmacists with red tape, while also putting more patients on prescription plans. The result: More prescriptions are being written.
"Most people have no idea of the impact managed care has had on medication errors and pharmacists' workload over the last five years," says Carmen Catizone, executive director of the National Association of Boards of Pharmacy.
Another factor cited by Catizone is the "unparalleled consolidation" of the pharmacy industry by large chains. The decline of independent pharmacies and mom-and-pop drugstores -- as well as the increasing use of mail-order and Internet pharmacies -- means a loss of personal contact between patients and pharmacists that can help minimize errors.
To make matters worse, pharmacies are squeezed by low reimbursements from managed care plans, forcing them to increase their volume in order to stay afloat. North Carolina pharmacy owner Gary Glisson, for example, says one of his stores will fill 90,000 prescriptions this year -- 15% more than last year.
At the same time, the clerical work involved in filling each prescription has become increasingly complicated and time-consuming. With insurance plans now covering two-thirds of all prescriptions filled, pharmacists are devoting much of their time to resolving issues of prescription benefit coverage.
Struggling to Prevent Tragedies
Experts across the country are trying desperately to devise methods to prevent tragedies like the one that claimed the life of Brendan Ward.
One partial solution is computerized prescribing. Doctors would send their prescriptions to pharmacies electronically, almost like email, hopefully preventing transcribing errors.
Another clear need is to train and hire more pharmacists. Between 1989 and 1999, while prescription volume was doubling, the number of dispensing pharmacists went from 171,000 to 180,000, a 5% increase. Increased staffing would allow pharmacists to actually do what's required under federal law: counsel customers. As it stands now, counseling occurs haphazardly, says Jim O'Donnell, an assistant professor of pharmacy at Rush Medical College in Chicago and the author of two books on pharmacy law.
"They do a token job," says O'Donnell. "As the cashier is ringing up the sale, they ask, 'Do you have any questions?' I've seen dozens and dozens of circumstances where pharmacists don't counsel patients, because they don't have the time to do it." That's too bad, says O'Donnell, because when pharmacists take the time to check for potential drug interactions and to explain to patients the proper use of medications, it makes a big difference. "It's been proven -- when pharmacists counsel, they catch mistakes."
To ease the squeeze on pharmacies, insurers also need to begin reimbursing pharmacists for counseling as well as traditional drug dispensing. "The bottom line is that no one is paying pharmacists for the way managed care is structured," says Randy Vogenberg, a pharmacy specialist at the Wellesley, Mass., office of ASA, a national benefits consulting firm. "We need to change how we pay for pharmacists' services and time."
Changes like these could begin to address the serious problems confronting an industry that are critical to the health and well-being of Americans. But experts also say that no number of reforms can substitute for another critical element of safety: informed consumers who make sure they understand from their doctor what drug they're being prescribed and what dosage they're supposed to be getting. The stakes, after all, could hardly be higher.
"When you're in a field like this," says pharmacist Adle Joseph, "there's no such thing as a minor incident. If you do something wrong, it's serious."
Loren Stein, a journalist based in Palo Alto, Calif., specializes in health and legal issues. Her work has appeared in California Lawyer, Hippocrates, L.A. Weekly, and The Christian Science Monitor, among other publications.
Rob Waters is a former senior editor at WebMD.