Why you MUST check the pills you get from the chemist
. . . far too often they’ll be the wrong kind — just one of the VERY candid confessions of a High St pharmacist
WITH more than a billion prescriptions dispensed in the UK by pharmacies every year, local chemists play a huge role in our healthcare. But what goes on behind the scenes may both surprise and alarm you, as this compelling journal from a pharmacist who works for a major High Street chain reveals. He wishes to remain anonymous to protect patient confidentiality.
CARELESS MISTAKES THAT COULD KILL
The first customer of the day has just arrived and I can’t quite believe what I’m hearing — the words every pharmacist dreads: ‘he’s been taking the wrong medication,’ says the middle-aged man, referring to the 85-year-old next to him, for whom he is the carer.
he hands me a creased paper bag with four open boxes inside and says the patient doesn’t usually take four different-coloured pills and that the names are different from the last prescription.
With sinking dread, I check our system. Sure enough, it says this patient has high blood pressure and takes three pills a day — but as the carer has spotted, this time he’s been given four pills to take four times a day. And they’re completely wrong: two different diabetes drugs, aspirin and a cholesterol-lowering statin, with not a blood pressure pill in sight.
This is a disaster. had the patient taken the pills for longer, his blood sugar levels could have plummeted, he could have fallen into a coma or died.
I ask the patient how he’s feeling and if he’s had new symptoms, then immediately call his GP to arrange an appointment that same day. I also dispense the correct medicines. Luckily, the patient seems fine, but when he and his carer leave, I notice the medicines were handed out the previous Friday while I was on a lunch break. None of the staff will own up, so I check the CCTv and find the dispenser responsible.
Dispensers help prepare prescriptions — they are specially trained — but a pharmacist must always check every prescription before it can be handed out. It’s clear that the dispenser hasn’t done the standard checks himself, either.
I tell him what I’ve seen. At first he denies it but then he apologises. It’s a terrible mistake and I have to log it so it’s investigated. As the pharmacist on duty, I will be cautioned; the dispenser is likely to lose his job.
This kind of mistake is fortunately rare — last year there were 10,000 medication errors across the UK, out of a billion prescriptions issued. But the stakes can be high.
Recently, a colleague at another pharmacy received an electronic prescription for a patient for a fentanyl patch — a very strong opioid treatment for chronic pain.
The pharmacy staff failed to properly check the label and note it had come by mistake from a care home 200 miles away. The problem was the patient’s name, which apart from the middle initial was the same as a patient this pharmacy had on file — an elderly man at a local care home.
So their patient got the fentanyl patch he didn’t need and used it for a day before a nurse noticed. This drug can affect breathing and could have killed him. As it was, he had to be monitored for a week. Mistakes happen about once a month in my pharmacy, so they’re exceptional, but I do sometimes wish I was the only member of staff because I fear others make more mistakes.
A few weeks ago, I had a call from a local hospital: one of our breast cancer patients had been admitted because she was ill.
While this could have been because of her cancer — which is terminal — they’d also discovered that instead of tamoxifen, our pharmacy had mistakenly given her the antidepressant paroxetine, which she’d taken for five days. Another potentially serious dispensing error in my absence. Can I ever leave others in charge?
There is an important lesson in this for patients to be vigilant of any changes in their pills. If they’re unsure of anything — the colour, shape, size — they should question it. Sometimes this is normal if the drug is from a different manufacturer, but it could just as easily be a mistake.
The incident with the wrong medication has distracted me for too long and there are now 15 prescriptions by the till for me to check. There are also five customers waiting to be served, the phone has not stopped ringing, and I have an appointment to give a family of four their travel vaccinations later.
Before I know it, it’s 5pm and I haven’t had lunch, and it doesn’t look like I will. In fact, I’m often here until at least three hours after my shift is meant to end. Two smaller nearby pharmacies recently closed, which means there are even more patients to see.
ERRORS IN ONE IN 20 PRESCRIPTIONS
The day starts with a thirtysomething woman who has a prescription dated for seven months ago. She was prescribed painkillers for back pain but apparently felt better after her appointment so didn’t pick them up, but now feels she needs them.
Unfortunately, there’s not much I can do: standard prescriptions are only valid for six months from the date on the prescription (prescriptions for controlled drugs, including strong painkillers, are only valid for 28 days).
So I have to tell her to go back to the doctor. She’s annoyed her doctor hadn’t told her that the prescription would expire, but GPs often forget to mention this.
The prescriptions themselves arrive in all sorts of states, sometimes completely incomprehensible. Last week I had one so illegible I couldn’t even hazard a guess as to what it said. I called the GP surgery and was told the GP would call me back.
I had to take the patient’s number and promised to call her once the prescription had been sorted. She wasn’t best pleased.
Two hours later, the doctor finally called back. Apparently the words said eye drops, one drop twice a day.
The problem is that I can’t just rectify a prescription myself, so I have to turn patients away until it’s sorted.
For example, there’s a prescription in my basket with the directions ‘take two daily for three days’ — but only one daily tablet has been prescribed.
It can also be tricky figuring out what doctors actually meant to write. The next prescription in my basket is for an asthma inhaler with the directions ‘one puff PR’ — that means one puff per rectum, clearly nonsense. I call the surgery and laugh about it with the receptionist, but again must wait for the doctor to call me back. I can’t guess how often the patient should be using it; it could be one puff or up to ten a day.
When the GP calls back an hour later, he explains he meant ‘one puff PRN’ — the abbreviation for the Latin
pro re nata, ie, use as required. As many as one in 20 prescriptions written by doctors contains mistakes, according to a review by the General Medical Council published in 2013.
There are some steps patients can take to head off some of these errors and delays. It may be as simple as checking the prescription as soon as you’re handed it: looking for the essentials — your name, the date and a signature — can save a lot of time.
It’s also important to keep prescriptions in a presentable condition. The number of crumpled coffee-stained sheets I see is ridiculous. Sometimes the hand-written ones are caught in the rain and are not legible, so again I have to turn patients away.
PEAK DAY FOR THE MORNING AFTER PILL
I SeRve a young woman who’s asking for co-codamol for her migraines. A healthcare assistant comes over and tells me she thinks she served her just yesterday for the same medicine.
The staff are trained to be vigilant when selling anything over the counter, particularly medicines prone to abuse or that cause addiction, such as co-codamol (which contains codeine and shouldn’t be taken for more than three days).
So I take the patient to one side and ask how often she takes the drug and if she was here earlier this week, but she says no. I have to believe her, though I don’t. Only if I have definitive proof can I refuse the sale.
Medicines such as high doses of cocodamol that don’t need a prescription but are only offered under pharmacist supervision are called over-the-counter pharmacy-only pills. These include nasal sprays for allergies and emergency contraception. The morning after pill is incredibly popular, I’ve had ten requests today. But my record is 22 — that was New Year’s Day.
HOW THE NHS IS BEING RIPPED OFF
TODAY starts with a ‘quick catch-up’ with management, though I know this will turn into the usual two-hour meeting. They ask: ‘Going forward what do we need to do?’ Translation: how and when I will meet their targets.
There are several, but the main target we’ve got to hit is for medicines use reviews (MURs). These are an NhS service for patients on regular medication, where they can get an annual review with a pharmacist to check how they’re getting on with the drug and get health advice. The pharmacy is paid £28 per MUR, with a maximum of 400 MURs per year per pharmacy.
I am asked daily by managers about how many MURs I’ve done, and if by the end of the week I haven’t met targets, I’m told I’m underperforming. It’s almost a form of bullying.
That’s not to say MURs are a bad idea — anything but: last week I saw a 77year-old who takes blood pressure medication but admits only doing so ‘when he feels like his blood pressure is going up’, ie, when he’s stressed or dizzy. This is dangerous and I told him to take it first thing in the morning.
But the problem with MURs is that while under pressure to meet targets, pharmacists end up picking the ‘easy’ patients to review — such as someone who’s been on the same pills for two years which are unlikely to change.
This MUR will be straightforward and won’t take long, but realistically the patient isn’t going to benefit much. But it means £28 for the company and a brownie point for me.
MURs cost the NhS a mind-boggling £92 million a year, and more people get them than actually benefit from them. This is shameful.
At today’s meeting I’m also reminded to push travel vaccines and get people signed up to our repeat prescriptions programme. All they care about is meeting targets: they forget we are here to serve patients’ interests.
A woman comes in with a photo of her 13-year-old son’s back. he has clearly been severely sunburned, the skin across the top of his back has
dissolved and it’s red, swollen and looks like it has yellow, infected edges. She asks whether I have a cream for it, seemingly unaware of how severe it is. I tell her that he needs to go to hospital and no over-the-counter cream will help.
Later, I brave another call to the GP whose patient we’d given the wrong pills to. I’ve been worried sick, just waiting for a call about him being taken to hospital. Luckily, he is doing fine.
A large, middle-aged man asks for saline drops for a blocked nose. ‘For a baby?’ I ask, because this is the most common group needing them. ‘No, for a big human,’ he replies, making me laugh.
DON’T TAKE YOUR HUSBAND’S PILLS
AFTer an early morning consultation about travel vaccines, I’m told there’s a man waiting for a private consultation about a rash.
I invite him in and discuss his symptoms and any medication he’s taking. I learn he also has swollen ankles and recently started taking the blood pressure drug amlodipine. his local pharmacy was one of those that recently closed and he wasn’t able to see his regular pharmacist; nor had he had an NMS (new medicines service), when patients prescribed a new medicine are given two fortnightly phone calls to check their progress.
had he kept the same pharmacist, these problems would have been picked up earlier. I tell him to see his GP as soon as possible.
I worry about the loss of continuity of care. Small pharmacies, and even larger pharmacies that aren’t overrun with work, can form relationships with patients.
recently, a regular patient asked for a fungal cream for a foot infection. I knew he had type 2 diabetes and refused to give it to him, explaining the infection might have been caused by his diabetes worsening and resulting in nerve problems. he agreed to see his GP. But if he’d seen a pharmacist who didn’t know him, when might the problem have been spotted?
A 67-year-old woman approaches the counter to collect her and her husband’s prescriptions. They are both on statins and a few other pills. I see that her GP has not given her the repeat prescription for her usual statin, so I mention it.
To my horror, she responds: ‘Don’t worry, I have plenty at home and just take my husband’s if I run out.’ Alarm bells ring. Why do they have extra stock, and why are they sharing prescription drugs?
I make a note to contact her GP, knowing that people do this all the time. In this case it wasn’t dangerous, but it can be, so never take someone else’s prescription drugs.
PATIENTS WHO TRY TO GET FREE DRUGS
I’M ALWAYS surprised by how many people [in england and Wales] say they are eligible for free prescriptions. While some are, I can’t help but raise an eyebrow at those with the Prada handbags and chanel sunglasses who get their paracetamol and hay fever medication for free.
I estimate 70 per cent of my patients get free prescriptions, but perhaps at least a third aren’t entitled.
We don’t have the power to check if people are telling the truth, but the Prescription Services NhS Business Services Authority does.
The phone rings and there’s an angry voice on the other end. A man says he’s been fined for wrongly claiming he’s eligible for free prescriptions. I am not sure how much he had to pay, but fines can be up to £1,000.
OFF-THE-SHELF TABLETS COST LESS
MANY people don’t realise that you can sometimes get prescription medicines more cheaply if you buy them over-the-counter.
A man turns up with a prescription for a steroid nasal spray for hay fever. It costs £8.40 on prescription south of the Border, or £6.50 over-the-counter. I tell him it’s exactly the same medicine and sell him it this way instead.
he could throw away the prescription (this won’t cost the NhS anything) but I tell him to keep it as the doctor has given him specific instructions on when to use it.
other cheaper over-the-counter medicines include canesten combi for thrush, a saving of £4.41 on the prescription version, while a pack of 32 co-codamol tablets saves you £6.90.
The day ends with one of my favourite customers, a man in his 80s. he’s a very loud character and always happy to see me. he calls me ‘the General’ and often just comes in for a chat.
he asks about the latest treatments for Parkinson’s, the disease he has, and I tell him about a recent study I’d seen about using electrical pulses to banish the shakes. he says he’s going to ask his GP about a referral, then thanks me for the great care.
I love my job.