In 2016 Khaliah Shaw went to a doctor’s office where she was prescribed lamotigrine. She filled the prescription at the pharmacy and began taking it. Several weeks later Shaw started to break out with blisters all over her body in fiery excruciating pain. She spent the next five weeks in a medically induced coma and was ultimately diagnosed with Stevens-Johnson Syndrome, a rare and serious disorder caused by an allergic reaction. It turns out, Shaw received the wrong dosage of lamotigrine at the pharmacy, an error that the pharmacist did not catch before dispensing the medication.
Stevens-Johnson Syndrome has left Shaw’s previously flawless skin burned and scarred as the disorder essentially causes the body to burn from the inside out. Shaw is also slowly losing her vision, her sweat glands are gone, and her finger nails will never grow back. There is no cure for Stevens Johnson Syndrome, and she could relapse. “They’re telling me this could happen again, and they’re telling me if it did happen again, that it would be worse,” said Shaw. According to the lawsuit filed on her behalf, medical bills have already reached more than $3.45 million. Extensive and prolonged medical care are expected to continue to add to those bills.
According to the Food and Drug Administration, prescription dosage errors jumped from 16,689 in 2010 to more than 93,930 in 2016 which is a 462 percent increase. The numbers come from FAERS, or the FDA Adverse Event Reporting System (FAERS), a database that contains information on adverse event and medication error reports submitted to the agency. FAERS is a voluntary reporting system, so the numbers are likely higher.
Matt Perri, pharmacy professor at the University of Georgia, cited reasoning for errors in that there has been an increase in the number of prescriptions being filled. Pharmacists are busier and under more pressure, making it harder for them to accurately do their jobs. To help resolve this issue some states are limiting the number of prescriptions a pharmacist can fill to about 150 per shift. Obviously the idea of setting prescription limits on pharmacists is unappealing to businesses, but from a patient safety perspective may be what is necessary to prevent such errors.
There are no restrictions on the number of prescriptions a pharmacist can fill per shift in Kentucky, and likely will not be an issue introduced in the legislature. The Georgia Pharmacy Association disagrees with prescription limits on pharmacists and says they are not convinced it cuts down on medication errors. Instead, they propose additional training on how to reduce medication errors.