An Unrecognized Cause of Medication Errors

Out-Patient generic drug vendor substitutions

I went to refill my medication this week and my pharmacist informed me that my usual medication is now being purchased through a new vendor. What last month was an orange pill now is a white one. He wanted to make sure I knew about this. I appreciated that he took the time to show me both pills to make sure I recognized the difference.

In my case, they filled half of my monthly prescription with the pills from one vendor and half from the other.. In effect I now received two bottles, one with orange pills and one with white pills, for the same medicine. At first, I thought no big deal; I really don’t care one way or another. This is not the first time that this has happened to me, but I asked the pharmacist how often these vendor substitutions occur. “More and more often now as we try to get the best deal on the medication to reduce costs. I have to educate my customers on a regular basis”.

Then I started thinking about the effect this would have on the average patient. I remember back in practice that when I would discuss medications. It often went something like, “Take the blue pill for your heart twice a day and the white pill for diabetes once a day.”. Not so simple nowadays!

I completely understand and agree with the concept of exchangeable generics. I am way past the concern that generics are not as good as name brands. I truly believe that for the vast majority of medications generic formulations, generics are equally effective. It makes sense that purchasing in bulk and using multiple vendors, is a very good strategy to increase competition among vendors and reduce pharmacy costs. We all know how critical it is to manage costs in the health care industry. Additionally, for many prescription benefit plans, the patient pays far less for generics. So, all is good, right?

To the average patient, especially one who does not have a medical background, this has to be utterly confusing. “Doctor, why is my blue pill now white and why is my square pill now oval?”

To make matters worse, with the increased incidence of chronic disease and the high frequency of multiple diseases, many patients are now taking more medications than ever before. It is not at all uncommon for elderly patients to be taking over a dozen medications. There needs to be serious daily planning on the part of that patient to make sure that the right medication is taken at the right times.

How can that person possibly keep them all of the medications straight, especially when the pill is changing color and shape from month to month? The physician and nurse would be typically unaware of this change and would not be in a position to assist the patient directly.

We should all be very concerned about the persistent number of medication errors in this country. We have known this for some time, ever since the Institute of Medicine Report showed that as many as 100,000 preventable deaths occur each year, and many are medication related. Fortunately, efforts such as the electronic medical record and better patient documentation have helped ameliorate the situation a great deal, especially in the in-patient setting. However, many medication errors persist in the out-patient setting. The out-patient problem is much harder to detect and much harder to manage because the drug is being administered by the patient without the hands on supervision of a medical professional. Currently, there is not good evidence that we have reduced medication errors in the out-patient arena.
I am impressed with what we have done as a health care team to reduce medication errors in our hospitals. We have come a long way since the Institute of Medicine Report over 15 years ago.

Now I believe we have to refocus our efforts to achieve better results on the out-patient side. The role of the pharmacist as an educator is certainly a very good start. Dealing with the ever changing colors and shapes of the medicines is just another hurdle we have to recognize and overcome.

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