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Incorrect medication supplied for the second time!

leon_heller

Graduate Poster
leon_heller
Joined
Jun 6, 2008
Messages
1,128
Location
St. Leonards-on-Sea, E.Sussex, UK.
About a year ago my local Boots pharmacy supplied me with Prozac instead of my usual Seroxat anti-depressant. I took them for a few days, thinking they were more or less the same, and started to get severe withdrawal symptoms. I took them back, the pharmacist was very apologetic, and said that the incident would be reported. I made an official complaint to the General Pharmaceutical Council (GPhC), and they took the incident very seriously. I subsequently got a letter saying that the two medications were now in separate locations and the staff involved were retrained.

A few days ago a similar thing happened, at the same branch of Boots, except that this time they supplied me with 30 mg Seroxat tablets instead of 20 mg. I took two of them before I noticed the discrepancy, thinking that the different size and colour indicated a generic equivalent. When I returned them the pharmacy assistant at first tried to fob me off by removing the label, putting it on a box of the 20 mg tablets, and saying that a note would go on my records. I said I was going to report them again, she went away and spoke to the pharmacist, who apologised profusely and said that she'd be making an official report. When I got home I downloaded another report form for the GPhC and filled it in.

Both incidents were quite minor, but could have had had a serious outcome if they involved a different medication. Checking the web, I found that such mistakes are surprisingly frequent, probably under-reported, and result in lots of deaths. Pharmacists and technicians who make such mistakes can be imprisoned, apparently, here in the UK, even if no serious harm results.

Has anyone else had a similar experience?
 
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Death panels and socialism and US healthcare RUUUUUUUUUUUUUUUUUUUUUULES!


That out of the way, no I haven't.
 
I was once given someone else's prescription entirely, when I went to collect my mother's medication at a branch of Lloyd's. Since I noticed immediately I arrived home, and took the bag straight back to the shop, no harm was done and I didn't report anyone. The pharmacist was extremely apologetic.

More recently, an independent pharmacist mixed up two similar-sounding eye drops for my mother. I spotted the bottle was different, thought at first it was just a different brand name, but when I compared the ingredients to the list on her old bottle I realised there was a difference. Again I returned them to the shop unopened. That pharmacist had been extraordinarily helpful some months earlier when the village was cut off by snow. He himself had ridden in to the shop on a tractor. My mother ran out of eye drops at exactly the wrong moment, and the shop didn't have the right ones in stock. The pharmacist telephoned her ophthamology consultant at the hospital 30 miles away, told the consultant what he did have in stock, and between them they worked out a modified regimen to tide her over until her prescribed medication could be obtained. Given that little lot, no, I wasn't going to report him either!

Rolfe.
 
At least at my pharm, when an item changes you get a sheet detailing exactly what the changes are. Also, the label has a description of exactly what the pill should look like. I check every time.
 
When I worked in a busy retail pharmacy, we once calculated that we were at least 99.9% accurate. That meant we still let one out of a thousand errors slip by. At close to 200 Rxs a day, it amounted to about one a week.

Most, thankfully, were "minor" and there was no harm done to the patient (at least no lasting harm!). About once every six months or so, a more serious mistake was made. In a couple of cases I called the cops or sent someone to a patient's house to intervene.

Never had one that amounted to more than embarrassment on my part, profuse apologies and a raft of paperwork. That's not entirely skill, there's some luck in there too.

So, yeah, it happens.

If you'd like something to worry about though, it happened much more frequently in a hospital setting than in retail. You'd think, with more professionals keeping an eye on things, the rate would be lower, but I found it was a bit higher -- weakest link, maybe? Also, in a hospital setting there were more extremes. Sicker patients that were more vulnerable to errors and more resources to counteract errors when they occurred.

Not to be callous about it, but I think patients overrate the mistakes that happen to them, don't usually do enough to double check stuff on their own, and are responsible for the vast majority of harm simply by not reading or following directions. This is excusable because they are not specifically trained and many don't adopt the role of "informed consumer." I wish they would.

How many reading this know the contraindications (listed on the bottle) for that Motrin (ibuprofen) you took last week?
 
I always read up any medication I'm given. I'm currently taking/using about 10 different items a day (I have Crohn's disease, a heart condition, sinusitis and basal cell skin carcinoma), making things a bit complicated. When I first had Crohn's disease 45 years ago, the hospital consultant obviously thought that I might have typhoid, as I found that the drug he prescribed initially was for that disease, and can have some very nasty side effects.
 
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Many years ago an insect got in my ear. We managed to get it out, but I still had ear-ache. Went to a doctor. He had a look at it and told me there was a scratch in my ear. Take this medication, I always prescribe it for ear things. When I got home I looked up what it was in my book. This was in the days before the Internet. One of the things said "do not use on scratches." The medicine went in the bin unopened.

Lesson for the day: Before using any new medication look up what it is, the side effects and anything else you can find. Do not rely on doctors to tell you this information.
 
I always compare the pill description on the bottle to what I really have. I've never gotten the wrong type of pills. However I did once get the pills intended for someone else. They were the exact same type I was supposed to get so it wasn't dangerous but I did have to go back in and let them know what happened.
 
I finished a prescription, went back to the pharmacy for a refil, noticed the pills looked different, told the pharmacist, she pulled out a big picture book and asked me to identify the pills I had been mistakenly given before. Pharmacist looked horrified.:jaw-dropp

I was lucky not to have been very sick, the person who go my prescription could have died, I hope that person caught the mistake.
 
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