Winning the Pharmacy Lottery

DECEMBER 21, 2014
"Lottery in June, corn be heavy soon."  - Shirley Jackson, "The Lottery"
 
My first exposure to the 1948 short story, "The Lottery," was in 7th grade -- not as a book, but rather a short film made for showing in classrooms. After watching the show, I remember thinking it was like something out of the "Twilight Zone" or late-night "Creature Feature." I am sure I slept with the light on in my bedroom for at least a week after watching that show.
 
In short, a small town has been practicing a ritualistic tradition in order to ensure a bountiful corn crop each season. This is how it has always been, few question its validity, and all participate in the atmosphere of a carnival, unless they are the lucky winner.
 
Through a seemingly random lottery drawing, first a family wins, and then in a smaller lottery, one of the selected family members draws the lucky ticket to become the town's lottery winner for that harvest season.

This is where the story gets a little dark.
 
The morning of the lottery, children may be found near the town park gathering rocks. Not little pebbles or skipping rocks, but solid throwing rocks, perhaps the size of a plumb or a small apple. By noon, businesses have closed for the day and the entire town's population has gathered in the park, excited and bursting with loud cheers of anticipation over who will be the winner of this year's lottery.
 
The morning before the drawing, absolutely no one thinks they will chosen. Out of the large tumbler, a family name is drawn. Next, all the members of the family draw a ticket, only one of which has a mark on it. The family member with the marked ticket is the unfortunate winner of the lottery for that year.
 
Slowly, but most definitely, the losing family members back away from the winner. In a short time, the town's people have surrounded the winner in a large circle, taunting and heckling the doomed community member. The first stone is cast, and then the second, and then a storm of rocks from each and every member of this community come pounding down upon the lucky winner of The Lottery. The stones continue until the winner has been sacrificed, and once again, the crops for the growing season have been given favor for a bountiful harvest.
  
In 2007, a landmark study performed by researchers from Ohio State University estimated that there were 5.7 dispensing errors per 10,000 prescriptions, or 2.2 million dispensing errors nationally each year. This translates to approximately 1 dispensing error for every 1750 prescriptions dispensed. In 2003, a study from Auburn University found that pharmacies processing more than 250 prescriptions a day made 4 errors daily.

While these 2 studies differ on their estimated percentages of inappropriately filled prescriptions, they are similar in the fact that they both document how pharmacies make dispensing errors on a regular basis.
 
Pharmacies have numerous safe guards in place to prevent the dispensing of a medication that has been filled inappropriately. As a practicing community pharmacist, I can say that every pharmacist I have known over my past 28 years of practice has been involved, directly or indirectly, in at least 1 dispensing error.
 
Although it is vitally important, my concern here is not to discuss the reasons why medication errors happen. Rather, what can patients do to ensure that the medications in their prescription bottles are the medications that the physician ordered?
 
Taken in the context of this article, a patient who receives a misfilled prescription has won the pharmacy lottery. If the patient then consumes the medication as prescribed, the results may be less than ideal, quite often serious, and sometimes fatal.
 
Following a few simple rules will greatly decrease the chance that a patient will consume a misfilled prescription.
  1. Always read the label to assure that the name on the prescription is the same as the individual who is taking the medication.
  2. If the prescription is new, assure that the tablet matches the medication description on the label.
  3. If the prescription is a refill, assure that the medication looks the same as it did last time. If it looks different, check the medication description on the label to assure that it matches the container's contents.
  4. Always call the pharmacist to verify the medication in the prescription bottle before taking the first dose, if there is any doubt as to what it is. 
Consumers may receive a misfilled prescription at some point in their lives. There is nothing they can do to avoid winning the pharmacy lottery. When consumers step up to the pharmacy counter to pick up their prescriptions, it is just the same as putting their hand in the big tumbler and pulling out a winning ticket. Although the odds are greatly stacked against it, it might just happen.


Steve Leuck, PharmD
Steve Leuck, PharmD
Steve Leuck, PharmD, has been practicing both hospital and community pharmacy for over 30 years. He founded AudibleRx, in 2011, which provides Consumer Medication Information which is both Useful and Accessible. Content designed to meet health literacy guidelines. Format designed to "read along" with the audio presentation in a simple to use web application. More information at AudibleRx.org.
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