Pharmacy board: Medication errors down in NM

‘Significant drug events’ fell nearly 35% last year

Medication errors that result in what are known as “significant adverse drug events” are down in New Mexico, according to a Journal analysis.

Each quarter, the state’s pharmacy board publishes a newsletter listing all such errors that were reported to the agency. To be considered a significant adverse drug event, the incident must involve an error with a patient’s medication, and the patient must have used the substance and experienced some form of mental or physical harm as a result. Pharmacists are required by state law to notify the pharmacy board within 15 days of when an event is discovered.

In 2018, there were 28 such events, according to the newsletters. In 2017, that number was 43.

Cheranne McCracken, the executive director of the New Mexico Board of Pharmacy and a registered pharmacist, said the change is likely due to normal yearover-year fluctuations. Still, she said the hope is that publishing the errors allows the state’s approximately 400 pharmacies and 3,000 pharmacists certified here to identify possible issues in their own organizations and prevent problems before they happen.

“We want people to learn from the mistakes of others,” said McCracken.

Among the significant adverse drug events reported in 2018:

A retail pharmacy gave a 12-yearold boy a substance used to treat opioid addiction instead of his prescribed asthma medication. The patient ended up the emergency room after a week, though he did not suffer any injuries. The pharmacist said the error was caused by a technician who did not give the medication to the pharmacist for a final check.

A 35-year-old woman was prescribed Navane, an antipsychotic, but was instead given the blood pressure medication Norvasc. The woman attempted to commit suicide, possibly as a result of the medication error, according to the phar-

macist. The pharmacist said the error occurred because pharmacy staff were having difficulty reading the name of the medication on the prescription, and the pharmacist misidentified the drug as Norvasc.

An 80-year-old man said he was hospitalized for a fall after taking an antibiotic along with his medication to treat an irregular heartbeat. The pharmacist reported overriding a computer warning for a possible severe drug interaction, thinking that the patient had safely taken the two drugs together in the past.

The most common roots of errors are look-alike or sound-alike medications, problems with the way a prescription is written and easily-confused medications stored near one another.

As for what patients can do to help prevent errors, McCracken said it is critical for patients to know their medications and contact a pharmacist immediately if something appears to be awry. It’s also helpful to use a single pharmacy, if possible, and to speak with the pharmacist about other conditions for which the patient is being treated.

“Look at the bottle and know what you’re taking,” she said. “You are the last line of defense.”