Why your healthcare experience should not have to depend on reading skills!
A close family member recently called to consult me about some of his medicines. He’d ordered his prescribed Ziplog from one of the online pharmacy delivery sites in India. The company sent back Ziblok, saying it’s the same medicine. Maybe, because it sounds same?! Ziplog-Ziblok… they sound different to me, but maybe it’s the same phonetics!
Anyway, my family member was confused and wanted me to confirm if the two medicines were indeed the same. I was aghast — not because they had sent Ziblok instead of Ziplog, but because when questioned, they confidently reiterated that these were the same medicine. These are, in fact, different medicines. While the one prescribed is a 2-drug combination for diabetes, the one that was sent was a drug for hypertension.
This episode got me thinking about the risks and the liabilities of these mistakes. It’s one thing to send the wrong medicine in error (that does not make it acceptable) though licensed pharmacists are supposed to be executing this process and one would assume they understand the difference between medicines for diabetes and hypertension. It’s another level of error, when confronted by the wrong choice, and presented the opportunity to correct an earlier mistake, you dig your heels in and confirm these are the same medicines. That almost seems criminal to me, an error of commission that could have far-reaching consequences on patient health. That got me thinking of the entire process that led to this episode.
Who was the individual that made the decision to replace Ziplog with Ziblok? What kind of training had he had? Who oversees his work and ensures he is adequately trained and kept up to date on the new brands hitting the market every month? Who trains him to take his responsibilities seriously and reminds him of the liabilities (legal, financial and ethical) resulting from his work?
How many people are sent the wrong medicines every day? Every month? Every year? Are these honest mistakes? Or is this a way to not lose a customer when you don’t have the medicine the patient is prescribed?
Who is tracking the impact of the wrong medicines prescribed? Who is liable? If the patients suffer a complication because of the wrong medicine, will the liability rest with the patient (for not checking the medicine they have taken), with the pharmacy selling the medicine or the doctor and the hospital? Will we even know if a complication results from a wrongly prescribed medicine? Will anyone even care?
I have worked in healthcare for more than 25 years and don’t have the answer to any of these questions. I don’t know who, if anyone, is responsible for answering any of these questions.
More than 250,000 people die in the US every year due to medical errors. I am not sure we track deaths from medical errors in India and honestly, selling the wrong medicine in this case does not seem like a medical error. More a brazen attempt to get by, because no one was likely to notice nor care.
Maybe, this was an isolated incident and an honest mistake. Maybe, this error was the first and last time a patient was sold a medicine other than the one prescribed. But maybe, this incident is a reminder that we need a systematic focus on the quality of healthcare we provide our patients. My family member may take his business to another pharmacy, hoping the pharmacist there can do a better job of reading the English name of the medicine. But as I argued a week back, there are millions of patients that are lined up to take his place as a customer for the pharmacy chain. Unless we start placing systemic safeguards, our family members run the risk of making do with sub-optimal healthcare experiences.
