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  • Writer's pictureSociety of Bioethics and Medicine

Medication Education: The Failures of Poor Patient Counseling

Written by Raheem Sheikh

Edited by Devika Baddhan

In the bustling city of Las Vegas, Nevada, Timika Thomas encountered challenges while trying to conceive after she and her husband decided to expand their family in 2019. Following two ectopic pregnancies—in which a fertilized egg implants outside the uterus, typically in a fallopian tube—Thomas underwent a procedure to remove her fallopian tubes, a necessary step due to the severe health risks posed by such pregnancies, including the unfortunate inability to save the developing embryo. However, fueled by her aspiration for a larger family, Thomas opted for IVF, embarking on a journey that involved specialized medications to initiate her desired pregnancy.

Shortly after her in vitro fertilization, her doctor prescribed her hormone medication. Thomas picked up her medication from her CVS pharmacist and recalled that she began “cramping bad” (Mitchell, 2023). It was then she realized she had been given Misoprostol instead of the doctor-prescribed vaginal suppositories. Misoprostol, typically used for treating stomach ulcers, can also lead to cervical softening and trigger uterine contractions in women. However, for pregnant women, its usage carries risks of miscarriages, premature labor, or potential birth defects. As a result, Thomas lost the two embryos she had implanted.

Following this tragic incident, investigations unveiled the involvement of two technicians and two pharmacists responsible for the grievous error. Documentation highlighted that one technician misinterpreted the generic name corresponding to the brand prescribed by Thomas’ doctor, consequently inputting the incorrect name into the prescription records.

Another significant issue with Thomas’ case was the lack of oversight at the pharmacy. A pharmacist failed to spot the error and another did not counsel Thomas at the time she retrieved the pills. Thomas believed the error could have been caught if “they would have had to have the medicine in their hand, and they would have said, ‘Oh, this is Misoprostol or Cytotec, have you taken this before?’ And I would have said, ‘No’” (Mitchell, 2023). Her case prompts important conversations about the role of patient counseling in healthcare. Studies have shown that effective counseling fosters positive therapeutic results when performed properly. Patient counseling can be defined as “advising the patient about medical dosage, directions for use, and lifestyle or dietary changes to be followed during the medication period” (Thevar, 2017). In Thomas’ case, perhaps the most significant goal to achieve is imparting awareness about the proper use of medication and its adverse side effects to patients because her loss could have, arguably, been avoided through open dialogue with her pharmacist. This raises the question: should pharmacists be responsible for educating users on their prescribed medications when they retrieve them? Or, do users also share the responsibility of inquiring and learning about their prescribed medications?

Through effective counseling, medical errors made in haste can be eradicated. According to a report published in September 2023, it has been estimated that $42 Billion has been associated with medication errors, globally (Eng, 2023). Adverse drug events most immediately cause millions of hospital emergency department visits annually. Prof Ong Chin Eng, the Dean of the School of Pharmacy, at International Medical University (IMU) in Malaysia, argues that pharmacists have two roles: (1) to ensure the safe prescribing and dispensing of medication to patients and (2) have the guidance they need to use the medication safely and effectively. There is an emerging opportunity for pharmacists to take a more active role in patient counseling, as they are central to the patient recovery process. Maybe, having learned about Thomas’ story, it is time to see them as trusted partners rather than just a drive-thru or pickup service. Telemedicine, specifically telepharmacy care, can make this possible because it breaks down geographical barriers that impact accessibility. It is important to consider options that not only improve the patient-pharmacist relationship but also do not impact the drug distribution system’s efficiency.

A study performed in Tehran, Iran, and published in the Journal of Research in Pharmacy Practice, investigated the role of pharmacist counseling in healthcare quality improvement. This project considered two major factors associated with poor outcomes: medication adherence and treatment satisfaction (Sanii et al, 2016). A total of 154 patients were placed in an intervention or control group. Patients in the experimental group received pharmacist counseling and education about their prescribed medication. Additionally, they were included in two follow-up schedules during the regimen, unlike the control group. The researchers found that medication adherence in the intervention group was 42.9% more than in the control group, and treatment satisfaction was 33.5% higher than patients in the control group. Patients in the experimental group were not readmitted to the hospital for any complications either. Dr. Yalda Sanii cites that one of the leading causes of adverse drug events (ADEs) and avoidable healthcare utilization is improper medication education. In their study, they listed useful methods for pharmacist-mediated counseling that were utilized on the day of discharge. Some included: medication counseling on all prescribed medications, comparison of discharge medication with preadmission regiments and reconciliation of discrepancies, and identifying potential drug-related issues like susceptibility to side effects. The study did not specify the criteria used to determine how much assistance is needed by each individual, which is important to consider if patients come from different demographics. Though these steps might seem expected from healthcare providers, their execution is not as widespread or efficient as they should be. In a non-medical context, consider a scenario where employees are not adequately trained or guided on using new software introduced in the workplace. Despite the expectation that they would receive comprehensive training, many individuals often do not get the necessary guidance or support in utilizing these tools effectively.

After complaining to the Nevada State Board of Pharmacy, the two pharmacists faced fines and provisionally lost their licenses—ones which can be reinstated over the next year. Moreover, CVS released the statement: “Prescription errors are very rare, but if one does occur, we take steps to learn from it to continuously improve quality and patient safety.” The company faced a maximum fine of $10,000 according to the statute (Bhaimiya, 2023). However, the question remains whether this monetary penalty truly compensates for the emotional distress and suffering endured by Thomas. Timika Thomas, still a grieving mother, is saddened because “all [she] got was a sorry.”


Bhaimiya, S. (2023, October 7). A woman who was accidentally given abortion pills by a pharmacy when she was undergoing IVF said her plans to have a big family were shattered. Business Insider.

Mitchell, A. (2023, October 5). Pharmacy accidentally gives abortion pills to patient undergoing IVF: “they just killed my babies.” New York Post.

Sanii, Y., Torkamandi, H., Gholami, K., Hadavand, N., & Javadi, M. (2016). Role of pharmacist counseling in pharmacotherapy quality improvement. Journal of Research in Pharmacy Practice, 5(2), 132–137.

Thevar, P. (2017, December 25). Importance of patient counselling for rapid recovery. Medium.


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