Faulty Drug Interaction Overrides: We Have to Do Better


We need a system that cries wolf only when a wolf actually appears--not every time a chihuahua dances by.

People who know me know I don’t have a lot that is good to say about the twenty some years I spent working for pharmacy chains. Chronic under-staffing, corporate edicts, flu shot quotas, and coupons for transfers and gift cards for those who had learned how to work the system were just part of what eventually led me to leave. Most of you reading this know exactly what I’m talking about. Sometimes though, the system seemed to actually work, and I’d spend part of the day answering phones, talking with patients, and getting prescriptions out the door like a well-oiled machine. I remember being in such a rhythm one afternoon when a little hitch developed. I was pressing my finger against the fingerprint detector to get past the interaction screen as I always did, but the computer didn’t seem to be moving on. It took me a few seconds to realize what was happening. There were no interactions to override. This happened so rarely that it threw me off my stride.

I let out a little chuckle at the time. I continued to remember it as just another humorous little pharmacy anecdote, until I came across an investigation published by the Chicago Tribune last December.1 They sent people posing as patients into 255 pharmacies with prescriptions for drug combinations with serious interactions-some potentially fatal. The result was an embarrassment to the profession. Fifty-two percent of the time the “patients” got the prescriptions without a word of warning or a phone call to the prescriber to double check that the prescriptions were OK. The best chain in the study still missed almost 1 in 3 potentially serious interactions.

Obviously something needs to change.

Which is why you might think it odd that it was the promise of one chain executive that his company “would improve policies and its computer system to "dramatically" increase warnings to patients” in response to that article that made me cringe. I would say though, that it is the “dramatic” increase in the number of warnings we see in the course of a day that has put us in this bind. When I started my pharmacy career, it would have been the appearance-not the absence-of a warning on the computer screen that would have thrown me off. Over the years though, liability lawyers and insurance companies have taken on a greater role in determining a corporation’s day-to-day operating procedures. The result? It’s thought a good idea to make sure we see things that have less of a chance of happening in the real world than me winning the Japanese National Sumo Wrestling Championship. Don’t believe me? Run “enalapril” and “hydrochlorothiazide” through your drug interaction software, then look to see if you have this “dangerous” combination on your shelf as Vaseretic or any of its generic equivalents. The drug interaction software at my last chain job also flagged a potential drug/age interaction between birth control pills and women of reproductive age. I’m not making that up.

So my reaction to the Tribune’s investigation was to call my software vendor to ask how I could have fewer interactions appear on my screen. My goal was to have my system cry wolf only when a wolf actually appears, and not every time a chihuahua dances by. And to those of you who’ll have to sit through some tedious computer-based training on the new “dramatically” improved policy, and procedures so your bosses can tell the corporate lawyers they did something, I have a word of advice.

Try to ignore it, and the other distractions that have been put in your way. Because it’s really important that we do better.


1. Roe S, Long R, King K. Pharmacies miss half of dangerous drug combinations. Chicago Tribune. December 15, 2016.

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