Pharmacist Error!!!

[Bina]

Does this ever happen to anyone else??
I have 2 prescriptions for Coumadin....2 mg and 3 mg. I know the difference and my hubby does also.
So, hubby (feeling crappy--3 more teeth extracted) goes to the pharmacy this morning to refill my prescrip. I place the bottle in a zip loc plastic bag. Usually I re-copy the med details on a piece of paper for hubby to use to verify the prescrip has been filled properly. Today I just give him the bottle in the bag.

He comes home and when I check the bottle I'm thinking "am I nuts? why do I have more 2mg pills here?" I go through my meds again.....nope, no 3 mg pills. So I call the pharmacist and ask if he got my Coumadin mixed up. He says no mix up, checks in his computer and tries to tell me that it's the 2mg we asked for....blaming my husband. I started to get upset, and so the pharmacist goes to look for the old pill bottle in the garbage....well, guess what? IT IS FOR 3 MG.
Then this guy blabbers on about this not being a real "issue" when I have 2 dosages for the same med that could be easily mixed up. and I should be sure to check things carefully.
I almost lost it, but I'm not to get stressed and spike my BP.

I pointed out that people can make mistakes, that is why he is supposed to be having a tech assistant check on the meds before giving them out.
So, I reminded him to re-study the importance and effects of Coumadin....if I would have blindly loaded up my pill box in my dimly lit kitchen and taken those 2mg pills, my INR would have crashed and I could have been a stroke victim.
He tries to recover and says " I know you need these pills, can I mail them to you?"
(I almost said: What are you a feaking moron??)
Instead I curtly replied that I trusted the mail even less than I trusted him at this point and my hubby would pick them up immediately.
Hubby gets to the pharmacy and the guy is waiting, prescrip in hand.
Hubby is angry; he snatches a business card off of the counter and tells the pharmacist to right down his name on it. The guy is now nervously shaking, but manages to do it.....turns out he is one of the Co-Owners of the pharmacy.
We had the same error about 2 yrs ago with the previous owners of the same pharmacy.

 

[catwoman]

Bina:

He's trying to lay his professional responsibility off on you.

I'd take the 2mgs by mail. (FREE) Then find another pharmacy to transfer my Rxes to. And let him know why. And I'd probably casually mention the incident to neighbors. Don't know about reporting it to any governmental agency that licenses pharmacists.

 

[Cooker]

I'm glad you caught the error ... And you are right, mistakes are made...Call this guy and give him the URL for Al Lodwick's site and tell him to bone up on "his" business.

 

[Bina]

Catwoman,
I'm feeling better now that I have the correct meds in my possession.... but it's very disturbing to know that these errors happen and I wonder how many seniors (especially) end up taking the wrong meds.
If I hadn't put on my eyeglasses I may not have noticed right away.
Not much chance of me switching pharmacies, I live in a rural area and the inconvenience for me would far outweigh the loss of my business to him.

 

[Freddie]

There was one time when I pick-up my prescriptions I received all the papers one gets regarding on the how to's and don't's about the meds. BUT I also received someones else's personal information . I had everything on this person, I mean EVERYTHING. I could have made millions doing the fraud thing.
I returned this form stating that "I hope this NEVER happens to me.....do you have any idea what I could have done with this information?" The pharmacist (a different gal) agreed that I could have done damage, and that she was looking for "that". I reminded her that if I start getting credit card statements and invoices from places I don't normally shop at, I'll know where my personal information was leak out.

 

[njean]

I've had coumadin refill mixups at least twice at the same pharmacy & other mixups w/some of my other meds too!!

One time in specific, I called in for my 7.5 coumadin refill & when I opened the bottom there were 10mg dosages in there! And I knew immediately because the 10 is white & the 7.5 is yellow! And too, I was wearing my eyeglasses!! I absolutely flipped! I drove immediately to the pharmacy & raised holy hell --- they still recognize me as the patient from hell!

I told my husband, thank God that I am not that old & feeble & can still tell immediately that I was given the wrong dose but can you imagine this kind of error for someone who is very elderly & puts their faith & trust in their pharmacy!

So I can absolutely relate to your anger & frustration!

P.S. My advice to everyone is to check their medications as soon as they get them because these type errors happen all the time!!

 

[Lisa in Katy]

That is why I no longer use Walgreen's. They are very convenient with their 24-hour drive-thru, but they are also very busy and have a high staff turnover. I used the 3 strikes rule with them - once wrong medicine which they claim was caused by doctor's handwriting (they gave me Valium instead of Warfarin and I probably could have used that!) and twice wrong dosage. The third time they even delivered the corrected prescription to my house. But it was too late. I too worry about seniors, but what about those people who have a new prescription and don't know what it is supposed to look like? Unfortunately, there are documented mistakes that have proved harmful.

BTW, even though I trust my current pharmacy, I always open the bottles before I drive away.

 

[Bina]

Freddie, there's another scary thought....A while back we received in the mail the pay cheque of an Air Canada pilot. He could have been ruined if his personal info fell into the wrong hands.

Norma, keep checking those prescrips. And when they screw up.....scream some more.

Lisa, I'm seeing a trend. Maybe we need to send a letter to Head Offices each time.

 

[ALCapshaw2]

INTERESTING Thread!

FWIW, I've NEVER had a mixup with my Mail-Order Rx's (from Medco or Pharmacare).

 

[Jkm7]

I have commented here that I am taking a very high dosage to try to reach my INR range. I will only be on coumadin for 2-3 months and am new to it since my recent valve replacement surgery.

We were out to dinner with friends a week or two ago and I commented to my girlfriend that it was worrying me how much warfarin I was taking and he (an Internist) asked "How much are you taking?" (Remember, this is not a professional office visit - - we are friends out for dinner.) When I told him how much, his first question was "Are you sure your pharmacy gave you warfarin?" His point being, I am new to the drug and might not recognize if an error had been made. The next logical sequence in this thought process is, there must be way too many pharmacy errors than we want to believe.

 

[warrenr]

Pharmacy

Pharmacy

Prescription error is one of the biggest causes of ADE's (Adverse Drug Events) leading to death or serious injury.

 

[KristyW]

Here's a story...My daughter had pneumonia when she was 3 years old (11 years ago). We were at the emergency room & the doc gave me 2 prescriptions...of course his writing is horrible & the instructions are in a sort of Dr code. I asked the nurse to tell me what it said and she said, "You don't need to know that, the pharmacist will fill it." I was floored! I told her, well pharmicists are human and the Dr's writing is horrible & I want to make sure I come home with what the Dr. ordered. She was quite rude with me!!! She brought the Dr back into the room to explain the prescription to me. I guess she couldn't read it either!


It's not just the pharmacists making the mistakes...the Drs do too, and their writing is bad!

I work in a dentist's office, and I am responisble for the prescription pad (can't sign it, but I type it out) I refuse to type the instructions as my dentist says them. i.e. "take i q6h " (That's take 1 every 6 hours) I want my patients to know when they leave me what the instructions are for their medication, AND I want them to be able to double check it on their way to the pharmacy.

 

[aussigal]

Its bad enough when we make a mistake dishing out our meds, we dont need the Pharmacist to help add to the mayhem. I check all my scripts for accuracy when I leave my Doctors office and again that I get given the correct pills at the counter in the Chemist. Nowadays I also stop and double-check my handfull of pills before I swallow them as I have had a couple of times where I wasnt sure what I had just taken. A few quick extra checks helps eliminate errors.

 

[Ross]

Its bad enough when we make a mistake dishing out our meds, we dont need the Pharmacist to help add to the mayhem. I check all my scripts for accuracy when I leave my Doctors office and again that I get given the correct pills at the counter in the Chemist. Nowadays I also stop and double-check my handfull of pills before I swallow them as I have had a couple of times where I wasnt sure what I had just taken. A few quick extra checks helps eliminate errors.

Bites when you find out you just ate 2 of your Coumadin pills instead of 1 huh?

 

[lance]

Number of pills per prescription ..........

Number of pills per prescription ..........

MY PCP has prescribed another drug I'm not coming off any time soon. So instead of his usual prescription for 35 capsules I asked instead for a prescription for 100 capsules which he gave me for 4 repeats of 100.

They filled the 100 capsule prescription once and then reverted to 35 because it's the only prescription they have on file. Even showing them the empty bottle with 5 repeats for 100 each didn't help.

More importantly the correct drug was dispensed.

I'm still irked because dispensing fees are charged more often than necessary. Our local pharmacy is a very nice place to visit--I just don't want to feel I live there.

 

[Bina]

I am not shy to ask a doctor to "translate" his writing on a prescrip....I will recopy it on my own notepaper for future reference.
Why should I assume that the pharmacist can decipher this garble and possibly kill me with incorrect meds. It's ridiculous.

Oh, and the price difference of 30 pills (2mg) and 60 pills (3mg), is $1.12 the fees are nuts.
My BP meds....same thing....I request 60 days worth for a couple of bucks extra.

 

[Praline]

I am looking at my asthma inhalor, Flovent. The directions for the last 2 months said,

"Squirt twice in each nostrils twice daily".

What if it was new meds and I did not know how to use an inhalor? It would be fun to try to squirt this in my nostrils. Do a lot of good too, you think??
The new prescription for this month has the correct directions.
They are just in too much of a hurry!!!!

 

[PairoDocs]

Med Errors

Med Errors

Just to tell you all that a lot of errors can be averted by carrying an updated med list OR your meds to the doctor's office for your visits. I would guess that almost everyone on this forum has more than one doctor or provider, and that they receive prescriptions from more than one provider. Don't assume your primary care provider gets letters or updates from the specialists; this is especially true for "sensitive" specialties like psychiatry. This is a huge deal, since psychoactive meds have so many interactions with other medications. For instance, there can be a prolonged Q-T interval with the combination of Geodon and digoxin. Toprol plus Geodon can cause tachyarrhythmias, and I'm sure many of you take beta blockers to slow down the heart rate. Cardiologists just don't have a lot of background with psych meds; our pharmacist runs everything through Medline Plus or whatever they have which is updated daily. Our pharmacist will always run this through for us. There have even been a few times that the pharmacist figured out the problem before the cardiologist did. I get patients all the time who ask me to fill their prescriptions from other doctors, and many times they tell me the wrong dose or say "Call the pharmacy" . If the cardiologist had added a medication and gave samples, the pharmacy will not have a record. Also, tell the pharmacist if you have allergies, so they can check and call the doctor if the doctor accidentally writes for something you are allergic to. I know for a fact that my handwriting is not good, and the pharmacists call me if they have questions. I tried a computer program to type it out, but we had so many printer problems and had to use special paper for controlled substances that all of us just gave it up.
None of us are perfect! Malpractice suits get filed because the provider does not admit wrongdoing or show regret. It would be a shame to have a good provider leave because of one mistake, thus compounding further the shortage of doctors and pharmacists. Yes, we have gotten the wrong prescription and had to take it back. This doesn't happen if I take the time to go through the prescription at the pharmacy before I leave. I also give the pharmacist an updated med list so they can update their data banks.
Hope this is helpful.

Starry Night In Idaho,
Laura

 

[ALCapshaw2]

Just to tell you all that a lot of errors can be averted by carrying an updated med list OR your meds to the doctor's office for your visits. I would guess that almost everyone on this forum has more than one doctor or provider, and that they receive prescriptions from more than one provider. Don't assume your primary care provider gets letters or updates from the specialists; this is especially true for "sensitive" specialties like psychiatry. This is a huge deal, since psychoactive meds have so many interactions with other medications. For instance, there can be a prolonged Q-T interval with the combination of Geodon and digoxin. Toprol plus Geodon can cause tachyarrhythmias, and I'm sure many of you take beta blockers to slow down the heart rate. Cardiologists just don't have a lot of background with psych meds; our pharmacist runs everything through Medline Plus or whatever they have which is updated daily. Our pharmacist will always run this through for us. There have even been a few times that the pharmacist figured out the problem before the cardiologist did. I get patients all the time who ask me to fill their prescriptions from other doctors, and many times they tell me the wrong dose or say "Call the pharmacy" . If the cardiologist had added a medication and gave samples, the pharmacy will not have a record. Also, tell the pharmacist if you have allergies, so they can check and call the doctor if the doctor accidentally writes for something you are allergic to. I know for a fact that my handwriting is not good, and the pharmacists call me if they have questions. I tried a computer program to type it out, but we had so many printer problems and had to use special paper for controlled substances that all of us just gave it up.
None of us are perfect! Malpractice suits get filed because the provider does not admit wrongdoing or show regret. It would be a shame to have a good provider leave because of one mistake, thus compounding further the shortage of doctors and pharmacists. Yes, we have gotten the wrong prescription and had to take it back. This doesn't happen if I take the time to go through the prescription at the pharmacy before I leave. I also give the pharmacist an updated med list so they can update their data banks.
Hope this is helpful.

Starry Night In Idaho,
Laura

EXCELLENT Information Laura.

Thank you for taking the time to write and submit it.

On a personal note, I find it hard to read and follow posts that are sent in one continuous paragraph, or more than one, but lengthy paragraphs.

To my mind (and EYE), separating thoughts and topics into smaller paragraphs is easier to read and comprehend if for no other reason than it is easier to keep one's place while reading.

Please take this as a "constructive suggeston" for presentation.

I am grateful for your thoughtful input.

'AL Capshaw'

 

[catwoman]

My veterinarians have written several Rxes that I have had compounded, or filled at a Costco or Walmart. These have been TYPED on their clinic's letterhead stationery. I recently filled an Rx for medroxyprogesterone acetate, 5 mg (Provera), 1 tablet a week, with patient name of Starfire. Very easy to read, no mistake about filling it or taking it. (And, yes, the pharmacy employee did raise her eyebrows. But the $4-a-month information didn't say it was restricted to HUMANS.)
Vets usually fill most Rxes at their clinic. However, I have had them write out Rxes for me to take elsewhere to save $$ (even mail-ordering them).

With the move toward computerizing all human medical records and, yes, Rxes, perhaps we'll also get the same as above: an Rx form written on clinic letterhead with a watermark (to verify authenticity).

We'll still have to contend with the Rxes being filled accurately, but perhaps the above will help.