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April 10, 1996

Pharmacies and Prevention of Potentially Fatal Drug Interactions-Reply

Author Affiliations

Brigham and Women's Hospital Boston, Mass
Harvard School of Public Health Boston, Mass

JAMA. 1996;275(14):1086-1087. doi:10.1001/jama.1996.03530380028023

In Reply.  —The study by Dr Cavuto and colleagues makes an important point—that computerized screening programs are not a panacea. Nonetheless, we believe that they can be an effective tool for preventing prescribing errors, particularly if they receive iterative evaluation and improvement. Moreover, the glass was more than half full in this instance: in 68% of the pharmacies, the error was intercepted. Of course, a 32% failure rate for an error with such serious consequences is unacceptable, but it might have been much higher had no systems to intercept such errors been in place.What went wrong in the instances in which the errors slipped through? It seems to us that at least three of the possibilities have important implications: (1) the drug interaction checking systems may not have been updated to include the new interaction; (2) the pharmacists may have been bombarded by so many interaction reports that they