12 Investigates: Medicine mix ups

RICHMOND, VA (WWBT) - An NBC12 Investigation reveals pharmacists and technicians across Virginia are making mistakes and it happens more often than you make think. The wrong medicine or dose could make you sicker and, in extreme cases, can even kill you.

Dispensing drugs is a huge responsibility and mistakes do happen.

In our review of hundreds of Pharmacy Board records from 2008 through April of 2012, we found 94 mistakes across the Commonwealth. In 42 cases, the wrong drug was given to a patient. 30 times it was the wrong dose. On 22 occasions, the pill bottles were mislabeled. And these are only the cases reported to the Virginia Pharmacy Board.

The number is small compared to the millions of prescriptions filled in those five years, but the mistakes we uncover sent dozens of people, including children, to the hospital.

"It's small when you look at it in the grand scheme, but each one of those errors is significant," said Amy Whitaker Rudenko. She's a practicing pharmacist and an assistant professor at the VCU School of Pharmacy. "That thought is always in the back of your mind, of, 'holy cow, did I possibly miss something?'" said Rudenko.

Many drugs sound alike or look alike. In some cases, it's the decimal point just dropped in the wrong spot — dramatically changing a dosage.

We found a case in the Commonwealth where a pharmacist accidentally gave a patient Oxycontin — a pain killer — instead of Singulair, their allergy medication. The patient was dizzy, disoriented and throwing up for 24 hours.

Another pharmacist gave a child Clonazepam, a muscle relaxer, instead of Clonidine, which is used to treat ADHD. (attention deficit disorder)

"Any error... that will keep pharmacists awake at night. There's no worse feeling that you have when you realized an error has happened." said Whitaker Rudenko.

A 2006 report from the Institute of Medicine, tells us medication errors harm an estimated 1.5 million Americans each year, resulting in upward of $3.5 billion in extra medical costs.

"We understand errors a lot better now. We know what types of things contribute to errors," said Whitaker Rudenko.

Rudenko says busy environments, not enough staff, bad hand writing, even problems entering prescriptions electronically can lead to errors.

Like most states, pharmacists in Virginia are not required by law to report their mistakes. The Virginia Pharmacy Board relies on calls, letters, and emails from patients and practitioners to launch investigations.

Last year, the General Assembly did pass a law requiring all pharmacies to have a plan to better analyze dispensing errors to prevent them from happening again.

"But no error is acceptable. We strive for 100 percent accuracy and a 0 percent error rate," said Whitaker Rudenko.

Our Research:

January 2008- April 2012
Wrong drugs dispensed: 42
Wrong dose: 30
Wrong label: 22
Number of known children given wrong medicine: 20
Number of known adults given wrong medicine: 7
Number of cases involving a Pharmacist "Diverting" drugs: 20
Number of cases involving Technicians "Diverting" drugs: 50

If you want to know more about the pharmacies in your area, you can use the pharmacy board license lookup site: link

You can search for individual pharmacies, but to see results involving errors, you need to know the name of the actual dispensing pharmacist or technician.

Copyright 2012 WWBT NBC12.  All rights reserved.