Guest Blog: A Near Miss. A Good Pharmacist. A Serious Lesson.

Last week I went to the family pharmacy I use in New York City to pick up a new anti-arrhythmic drug that might slow down or even stop the atrial fibrillation I had experienced for the previous two weeks. The pharmacist came from behind his privacy wall to speak with me before dispensing the drug. He wanted to know if the same doctor who had prescribed the blood thinner Coumadin for me had also prescribed this anti-arrhythmic drug.

'No,' I responded. 'One was a cardiologist and the other a hematologist.'

"Have the two doctors conferred about you taking this new medication?' he asked.

'No.'

'You should speak to your hematologist before taking this anti-arrhythmic because this drug can radically alter the dilution of the clotting factor in your blood. This drug could throw your blood way out of whack and potentially cause bleeding.'

I thanked him for his professionalism and concern for my health and left feeling like I had narrowly escaped being run over by a bike messenger and pleased to be filling my prescriptions at this place where the pharmacist was so vigilant.

Now as a patient, one would prefer to forgo the risk of extraneous bleeding, whether intracranial or intestinal, right?

The pharmacist had taken the time to check his files ' or the new prescription triggered an electronic alarm in my computerized record ' where it was recorded that I was taking a blood thinner. And he thought the possible interaction between the old and new prescriptions was sufficiently dangerous to alert me of the possible effects the new medication might have on the current medication I was taking.

The cardiologist who had prescribed the drug made no mention of the possible interaction of the two drugs even though he was fully aware that I was taking a blood thinner. We had spoken just hours before about my most recent blood tests. I know he knew I was taking the blood thinner. Was he not paying attention? Did he not know of the potential danger? Does he not have an electronic health record that would notify him of it? Hmmm.

This raises two points for me:

First, that we really can't depend on our doctors and pharmacists to remember the drugs we are taking and to avoid prescribing (and filling the prescriptions) of ones that pose a safety risk. We have to remind them.

This is really too bad. I am an experienced patient with a couple serious chronic conditions and a long history of participating in my care. I should have known better than to trust without verifying. And I know that it would never occur to many of my fellow patients to do so. But really, this situation shows both how easy it is for clinicians to err and how important it is for us to second-guess/challenge/check on our doctors' decisions.

I have on occasion been the recipient of irritated words for this kind of diligence, but when you experience a near miss like this, you realize that such checking has got to be an everyday fact of your life as a patient if you are going to avoid the errors of distracted, over-extended physicians and pharmacists. Hence, the recommendation is that we should carry our list of current prescriptions and dosages with us to every appointment. But really we should probably have it with us at all times in case of an emergency.

I always carry my medication list with me on my smartphone. When and if I flash it to my doctors, their faces light up. They realize they don't have to search through their messy paper files to see what they last prescribed. It can be a memory aid for me and a time-saver for them.

The second point raised by this incident: I am so grateful to my pharmacist. I guess I hadn't seen him as fully part of my team before, but I do now. I know he has skills and knowledge that can ensure my medications are safe for me. I will make sure I get all my prescriptions filled at that pharmacy in the future and will always check with him as well, to be absolutely certain that someone somewhere (besides me) is scanning for problems and redundancies.