In this issue of the Journal of the American Pharmacists Association, researchers from Auburn University⁺¹ report their study of dispensing errors in 100 chain pharmacies that served as the basis for a sensational segment on the ABC News program 20/20 in March 2007. For those who may have missed the 20/20 story when it aired, their results remind us that the axiom “to err is human” also applies to the processing and dispensing of prescription drugs.

One could quibble, and I do, with a number of things that were done in the study, as well as some that were not done. For example, defining “dispensing error” to include putting too many or too few tablets into a vial would seem to dilute and trivialize the term. Certainly, the potential for harming the patient would appear to be rather remote. Also, why use handwritten prescription orders? They are destined for the trash heap of history and contribute nothing but a potential source of bias if the objective is to quantify dispensing errors that are exclusively attributable to pharmacy staff. Using typed prescription orders would have avoided this possible confounder entirely, as would eliminating abbreviations in the Sig (directions) portion of the medication order. Why use employees of ABC News as observers when they clearly have a vested interest in the outcome of the study? After all, who would want to watch a segment of 20/20 that screamed, “Chain pharmacies are safer than ever!” Using independent shoppers would have eliminated any concerns about possible bias. Additionally, the number of patrons standing at the pharmacy counter would seem to be a very crude measure of pharmacy workload. (The researchers use the term “busyness.”) A more direct and relevant indicator would be the volume of prescriptions processed per hour divided by the number of pharmacists and technicians on duty.

Despite my misgivings about the study's methods, the article provides us with a reason to revisit the important issue of improving prescription drug delivery in the community practice setting. I am willing to accept that preventable errors remain in the system and that patient counseling is far from perfect. The more important question and the one that 20/20 failed to address when they aired the story is, “How can we continue to improve the safety of medication delivery in the community setting?”