In the ongoing debate about reforming the health care system in the United States, those resisting change often start with the mantra that “We have the best health care system in the world”. The response, of course, is that the last time the World Health Organization provided such ratings, the US actually came in at 37th place despite spending more than any other country.

Most of the current debate on reforming the health care system is focusing almost entirely on reforming health insurance, with a bit of discussion carrying over to address the companies manufacturing pharmaceuticals. These areas are very good targets for reform. However, two recent episodes for my family underscore another aspect of the health care industry that is need of reform but gets very little attention in the current debate. A 2003 study in the Journal of the American Pharmacists Association concluded that the rate of errors in filling prescriptions is a problem:

Dispensing errors are a problem on a national level, at a rate of about 4 errors per day in a pharmacy filling 250 prescriptions daily. An estimated 51.5 million errors occur during the filling of 3 billion prescriptions each year.

Although this study did not find a difference in error rates depending on the type of pharmacy, many believe the consolidation in the pharmacy industry is leading to a decline in the quality of service. Chain drug stores now account for over 75% of sales and “the top four—Walgreens Co., CVS Corp., Rite Aid and Eckerd—claim about 66 percent of the industry’s total market share”.

As noted in this blog post, 20/20 (caution–it was a Brian Ross report and he is not always reliable) broadcast results of an investigation of prescription errors in 2007. Here is a quote from the blog post, where the footnotes refer to the 20/20 broadcast:

According to Bill Kennedy, former senior pharmacist for Walgreens, overworked pharmacists are pushed to fill prescriptions at a very high pace [8].

Kennedy’s job was threatened because he would not work as fast as Walgreens wanted [1].

“Walgreens has always had a problem with me that I don’t “keep up” getting the prescriptions out in a timely manner.”
“I’m slow [...] because I take the time to do what I think is the way to do the job properly.”

Indeed, pharmacies are so busy they rely heavily on pharmacy technicians, often high school students, that are allowed to fill prescriptions.

Did you get that? Some pharmacies allow pharmacy technicians, often high school students, to fill prescriptions.

Going back to the journal abstract quoted above, that study found that 6.5% of the errors they encountered in the study were “clinically important”. From their figures (6.5% of 51.5 million errors a year) then, over 3.3 million clinically important errors a year occur in filling prescriptions.

As mentioned above, two recent episodes for my family drive home these problems with the dispensing of prescriptions. Just over a year ago, our older daughter had a sudden, severe stomachache coupled with nausea as she was getting ready for school one morning. After a frantic half hour of worry and investigating, we found that she had taken the first tablet that morning from a recently refilled prescription of an antibiotic used to control acne. The new bottle had tablets of twice the prescribed strength.

We filed a complaint with the state and used the episode as a reason to switch from the convenience of a nearby chain pharmacy to the only independent pharmacy in town. Service there has been personal and excellent, but the pharmacy is not open on Sundays and that became a problem yesterday.

Our younger daughter started to not feel well Saturday evening, complaining of a headache and scratchy throat. By early afternoon Sunday, her fever spiked to 102 degrees and she had muscle pain all over. Since she already had gotten the seasonal flu vaccine, we presumed this was an H1N1 infection. I got on the telephone quickly, and after having to get a bit pushy with the answering service for our family doctor, got through to a doctor on call. He agreed to call in a prescription for Tamiflu. Since Tamiflu is most effective if administered early in a flu infection, I wanted the prescription filled right away. I chose to have the doctor call the other major pharmacy chain in our town (two chains control the market here since I won’t even consider pharmacies inside discount or grocery stores) instead of the one that made the antibiotic error.

I went down to the pharmacy and waited for the prescription to be filled. And waited. The pharmacist and the technician were very nice and kept checking the pharmacy voicemail to see if the prescription was there, but it did not come. After about an hour and a half of waiting, I went back home to wait. At about two and a half hours, I contacted the doctor again. He said that he had called in the prescription within five minutes of our first conversation and had even talked to the pharmacist in person. He agreed to call the pharmacy again.

The second try did produce the prescription, which was quickly filled. After a bit of prying with the technician, I made a discovery that I found jaw-dropping. For this particular chain, when a doctor calls in a prescription, the call is handled at a centralized calling facility if the doctor actually talks to a live person. This person processes the information and eventually forwards it to the local store. If the doctor instead is routed to voicemail, that voicemail shows up at the store immediately. My doctor’s second call had gone to voicemail. The technician said that he would delete the original prescription when the information eventually came through, even though it was not there yet three hours after the original call.

The bottom line is at least for that particular chain, if you want your prescription quickly, tell your doctor to hang up if they get through to a live person and keep calling back until they get voicemail–exactly the opposite of what I would have thought to be the preferred method.

The good news is that the Tamiflu seems to be doing a good job for my daughter. Her fever is gone this morning and the coughing is reduced enough that she is getting restful sleep.

It seems to me that the “best health care system in the world” could do better than making over three million clinically important errors in filling prescriptions every year.