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News broke this past weekend that a New Jersey CVS had mistakenly provided families with the breast cancer drug, Tamoxifen, instead of chewable fluoride tablets meant for their children. Reports are that as many as 50 families between December 1 and February 20 may have received the wrong pills. Fortunately, all reports are that it is very unlikely that any of the children would have been harmed by taking the breast cancer medication.

We must now make sure that incidents like this do not happen in the future. A article published in May 2003 in the Journal of the American Pharmacists Association reported on a study (National Observational Study of Prescription Dispensing Accuracy and Safety in 50 Pharmacies) which was undertaken to assess the dispensing accuracy rate in 50 pharmacies in 6 cities located across the United States. The study found that the overall dispensing accuracy rate was 98.3% (77 errors among 4,481 prescriptions). Of the 77 errors, 5 were judged to be clinically important. The authors concluded that “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.” Obviously, this is way too many.

Pharmacies have programs and protocols in place so that dispensing errors do not occur. We must make sure that our pharmacies not only follow their protocols, but they must be constantly reviewed so that they can be updated and enhanced so that errors, such as the ones that were reported on this weekend, are not repeated. The medication mix-up that occurred at the New Jersey CVS must be studied carefully so that all in the pharmacy industry can learn valuable lessons.

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