Would you have done the same? Recieved wrong prescription.

Nurses General Nursing

Published

Okay

Here's the deal.

I'm in my last semester of nursing school and I'm also staying with my grandfather because he had an MI last January and was in ARF, then followed on an intermediate care unit and D/C'ed with cardiac rehab. Now he also has bladder cancer, so he does need someone here with him. He takes all kinds of meds. One in particular, is darvocet, in which he takes it regularly for shoulder pain.

I ordered two meds for him on Monday the 19th. I didn't realize that the scripts were over with on these meds, so I requested that the pharmacy call his primary care physician for an authorization that would hold him over until he's able to get in for an appointment (this is a chain pharmacy, I won't give names in case they're reading this).

So it was required that I give them at least 24 hours to call his doc. I gave them two. Grandpa picked up the meds on Wednesday. One was his usual blood pressure med that I ordered, and the other one I didn't recognize. I opened the bag, then I opened the pill bottle. I didn't recognize the pills. Then I looked at the label and realized that this med was meant for someone else, with a similar sounding name as my grandfathers. No biggie, I was a little concerned because my grandpas vision isn't all that great and if I wasn't living with him he would have never noticed. Another concern was that the wrong med he recieved was a narcotic. Oh boy who knows what would've happend if he was taking TWO narcs.

Anywho, I didn't make a fuss over it. I took the wrong meds right back to the pharmacy. I explained to the pharm tech what happend and that I just wanted to give them back and get the meds that should've been ordered.

The alarming part, was that he took the narcs from me, and put them right back into the customer pick-up bin, without checking to see if the bag had been opened, or even verifying that the narcs were there, and he didn't even count them.

If I wasn't an honest person, I could have really just thrown some tic-tacs in there and called it a day, but I'm not like that.

I wrote a formal e-mail complaint to this pharmacy, and have yet to hear back. I remember the name from the medication bag, and went to whitepages.com and found his phone number. Should I seriously call this guy and tell him to file a complaint with the pharmacy, re: HIPAA violation & potential med tampering? I think he really has a right to know what COULD have happend.

Are there protocols in place for pharmacies for these situations that arise? I would have imagined that they should have taken the narcs back, wrote up some kind of report, threw the meds in the trash (or kept somewhere for investigation) and just re-do the other guys whole prescription?

Let me know what you think!

You did the right thing. This has happened to all of us pharmacists at some time, and it's horribly embarrassing.

As long as you, and we, tell the truth, nobody's going to get in trouble.

BTW, once drugs leave the pharmacy, they cannot be returned to stock.

Thanks everyone for your responses.

I did not call the guy who the meds were intended for. I figured it wasn't worth opening that can of worms since *I* knew that I had not tampered with the meds.

I recieved a phone call from the pharmacy regional manager yesterday. She was very nice and frankly embarrassed about the situation. I assured her over and over that I wasn't upset, that I wasn't out to get someone in trouble, or trying to score a gift card. I told her that I understand people make mistakes but the way the situation was handled could've potentially put the other guy at risk.

The reason I did not bring up the issue at the pharmacy, is because there were several people waiting in line behind us. There were also several people sitting down in the chairs. Making a big stink about an error like that in front of all those people could have potentially caused a frenzy. Also, grandpa has bladder CA and has problems controlling flow so he said hurry up I need to use the bathroom so let's go.

Anywho, the pharmacy regional manager went to the pharmacy that day, checked records and did find that the medication was re-sold to the originally intended customer and that protocol had not been followed.

She said this is what should have happend:

1. We bring the medication back and are refunded the cash paid

2. The medication is taken out, placed into a plastic baggie and locked up until all the documentation is completed and all the narcs are accounted for.

3. An incident report is filed (Just like our incident reports - which are meant to be educational and not punitive)

4. The originally intended customers medication is re-done

She did mention that the mistake should've been brought to the pharmacists attention, as he would be the one ultimately responsible.

She also said that she visited the store, and had a meeting with all the techs, pharmacist and team leaders. The incident was brought up and discussed in detail. She had a one-to-one talk with the pharmacy tech and he will be re-taking a learning assignment regarding medication safety. She said he did have to have the incident added to his record because it involved narcs. She said the best thing that could've been done to avoid the mistake was to cross-reference the patients date of birth, it could've been caught at that point. He stated he did feel bad, and that he didn't know what he was thinking, and that the pharmacy was very busy at that point in time and he just thought he'd save some time.

For anyone who is criticizing me, what if I was less than an honest person? I mean seriously, narcotics are routinely sold at high street value prices. Someone else may have seen it as an opportunity to make some money. I understand human error, but seriously, what if I did take the narcs, re-fill the bottle with some OTC medication the poor other customer was allergic to and he keeled over and died. The pharmacy would have been at the wrong end of a lawsuit. Medication labeling changes all the time, grandpas potassium pills used to be in a capsule, then one day they changed into a round yellow tab. I hope that one day you never recieve medications that someone else recieved and they were just re-shelved.

Specializes in ER, Med/Surg.

Glad things turned out best for everyone. I'm sure the pharm tech has learned HIS lesson!

Pat

I've been a nurse for quite some time and all of my patients have been taken care of professionally at all times. These "I wouldn't want YOU to be my nurse" statements are immature in nature and childish. All I was trying to convey was that the situation should have been handled right then and there INSTEAD of causing a big stink about and having this guy's record marked (I'm sure he appreciated that!). It would have been much easier to have said "Dude, that's not how you supposed to do it." and the problem would have been solved. Just like this guy said to the Manager, he was very busy that day and he didn't know what he was thinking. I feel sorry for this guy.

I've been a nurse for quite some time and all of my patients have been taken care of professionally at all times. These "I wouldn't want YOU to be my nurse" statements are immature in nature and childish. All I was trying to convey was that the situation should have been handled right then and there INSTEAD of causing a big stink about and having this guy's record marked (I'm sure he appreciated that!). It would have been much easier to have said "Dude, that's not how you supposed to do it." and the problem would have been solved. Just like this guy said to the Manager, he was very busy that day and he didn't know what he was thinking. I feel sorry for this guy.

What if you were on the recieving end of tampered meds? especially narcs. would you still think that taking a remedial medication safety course and a tap on wrist would be so harsh of a punishment?

would you do the same in your practice as a nurse?

I'm glad you were able to resolve the issue with the manager. It sounds like steps were put in place to ensure this doesn't happen again which is very important. I'm also pleased to read that the pharm tech will get the additional training he needs.

Such dramatic scenarios to back up your points! Death, death, death. This guy did not die. He didn't even take the medication. Put on your critical thinking cap and stop spewing typical brain-washed nursing school jargon.

God, I hope YOU are never MY nurse....

Please come up with something a bit more constructive and less of a quick and easy personal attack.

Please come up with something a bit more constructive and less of a quick and easy personal attack.

I've already contributed what I thought was a constructive reply to the OP and was simply reacting to what you wrote; no different than your post saying that others were overreacting. I think you are underreacting.

Just speakin' the truth.

Your opinion does not constitute truth. I stated my opinion, and you have stated yours. I do not appreciate personal attacks, which is exactly what people do when they have nothing else to say.

Specializes in ortho, hospice volunteer, psych,.
I've already contributed what I thought was a constructive reply to the OP and was simply reacting to what you wrote; no different than your post saying that others were overreacting. I think you are underreacting.

Just speak' the truth.

I agree also and not because the answer is "quick and easy" but rather because I would not have wanted an RN or LPN taking care of my mother or mother-in-law when they were dying of breast ca that had metastized to several new organs, thus requiring many meds to keep them comfortable, with an attitude such as yours. They both had a great many meds to keep them comfortable and as some looked a lot like others, their nurses had to be mindful that the correct meds had been sent. Before you ask, we were over 1000 miles from my in-laws and my mom's dementia caused her to believe she was in the condition she was because we (the family) were trying to murder her. Hence, we had private duty RNs provide around the clock care and they were all careful about her meds. Are you, by any chance a new nurse?

sharpeimom:paw::paw:

The truth is that I wouldn't want someone as my nurse who thinks medication errors (especially involving narcotics) are no big deal. That's all I'm saying.

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