Colorado Pharmacists Not Required To Counsel Patients

Pharmacies Supposed To Confirm ID Before Dispensing Drugs

Pharmacists in Colorado are not required to have conversations with patients about new medications.

7NEWS highlighted the medical mistake that could cost a Fort Lupton woman her unborn child. Mareena Silva went to a Safeway pharmacy for an antibiotic, but was given methotrexate. Methotrexate is a drug used in chemotherapy regimens to treat cancer, but it is also used to terminate early-stage pregnancies. The methotrexate was meant for a patient with a name similar to Silva's.

"All pharmacy personnel are instructed to ask and listen to the patient's full name and date of birth before retrieving medication from the 'will call' area," said Safeway in a statement sent to 7NEWS Tuesday.

The statement added that pharmacy personnel must repeat the information back to the patient prior to handing out the medicine.

7NEWS has learned prescription mistakes are not limited to Safeway.

"Nobody came up and verified my address and checked to make sure I knew how to take the medication," said Silverthorne resident Josh Gammel.

Gammel isn't your average Silverthorne 20-something. The man who loves to snowboard, can't. He lives at home with his parents and is often nauseated or in extreme pain. His spine pinches his brain stem, causing his need for morphine prescriptions.

"It's kind of a part of every day life now. Wake up, assess how I feel (and) start moving if I can," said Gammel.

He told 7NEWS that twice at King Soopers pharmacies in the Denver metro area, he got the wrong prescription.

In one incident, he said he was given a 40-milligram dose instead of 30-milligram. In another incident, he said the type of morphine he was given could have killed him.

"It was supposed to be the extended release medication that I'm on. It was actually, it looked like it was the instant release medication," said Gammel. "If I had taken it the way I was supposed to, I could have ended up in the hospital … if I was lucky."

"My son needed his medication immediately, he was in agony," said his mother Cathy Gammel. "So luckily, while we were still standing in the pharmacy, he opened the bottle and he knew it was wrong. (The pharmacist) said, 'Oh sorry, I didn't recognize that medication on the prescription.' If my son had taken that medication without checking it, his heart rate could have slowed, his breathing could have slowed."

According to Cathy Gammel, in both instances, the problem was corrected on the spot. On one of the two occasions, she said she was contacted by store management as a follow up.

"Perhaps the grocery stores that are for profit are not necessarily the best places to have pharmacies if they're not able to have them staffed properly and procedures handled properly," said Cathy Gammel. "People all over the state of Colorado are in danger if they do not check their medications when they pick them up. They need to check to make sure it's their name. If they don't recognize the medication, they need to speak to their pharmacist."

"In the state of Colorado, we are not mandated by the state board via legislation to counsel the patient," said Gina Moore, a pharmacist and associate professor at the University of Colorado School of Pharmacy. "If we mandated counseling, there'd at least be a conversation about, 'do you know why you're taking this medicine?'"

Moore said other states have legislated that pharmacists counsel patients about new medicines. She teaches her students to have a conversation with patients about new medicines so they know what they're taking and why they're taking the drug.

"They're evaluated and graded and given feedback on their interaction, their comfort level, how they engage the patient (and) whether they ask open-ended questions," said Moore. "You should absolutely engage the person in a meaningful conversation about what their medicine is, why it's being used and what they need to watch out for."

"I think the procedures need to be more precise and followed to the letter, because we are talking about people's lives," said Cathy Gammel.

"I count them every time I'm at the pharmacy now, because I don't trust any of them," said Josh Gammel. "You expect to be able to trust a doctor and trust the pharmacy, they went to school for these (things), but they are just human."

According to Moore, patient identification should be confirmed before every medicine is handed out. She teaches her students to confirm the patient's address and makes them ask a question like, "What is your address," and not "Is your address 123 Main St?"

"For any new medication, what we teach and we hope that pharmacists are doing in the community is asking open-ended questions and engaging the patient in a discussion about the medication," said Moore.

"Is there a reporting process in place if mistakes are made?" asked Zelinger.

"There's voluntary processes in place with error reporting to ISMP which is the Institute of Safe Medication Practices," said Moore.

The ISMP compiles a list of commonly confused drug names so pharmacists can be aware of drugs that have similar looking or similar sounding names, but are prescribed for different reasons.

The drug names are also spelled partially with capital letters, called "tall man lettering," to point out the differences between drugs.

"It's drawing attention to the fact that they're two unique drugs that should be distinguished between each other," said Moore. "Drugs end up on this list because there was a dispensing error with the drugs being confused for one another."

7NEWS checked with the Department of Regulatory Affairs and found out that the Board of Pharmacy does investigate pharmaceutical mistakes, but only if they're self-reported.

Safeway told 7NEWS it will self-report the mistake from Fort Lupton, once their investigation is complete. Patients can also file a complaint with the Board of Pharmacy, which is required to do an investigation in response.