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!

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Phew; that's a tough one! I think you, of course, did the right thing by doublechecking the meds and returning them to the pharmacy and notifying them of their error. I do not, however, think you should contact the other patient. Maybe that is wrong? I don't know. I DO think you should make sure that management at the pharmacy are aware of the error AND especially the name and actions of the person who nonchalantly took them back the way he or she did. It scares me to think that they would do so right in front of you; makes you wonder what errors they ignore when nobody is looking?

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Specializes in Emergency.

The returned medication should have been given directly to the pharmacist. When narc pills are dispensed, they are double-counted, initialed by the person who counted the pills, and verified by the pharmacist. Since the meds left the pharmacy, they should have been re-processed once they were returned. After a direct count was made, its my opinion that the pills should have been disposed of by the pharmacist - the meds could no longer be properly accounted for and could have been tampered with.

Don't let this one slide. Call and ask to speak to the pharmacy manager and document the details of your phone call. Then, contact the district manager to report your experience, who you spoke with, and what they said would happen to prevent this situation from recurring.

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Specializes in Geriatrics, Transplant, Education.

Yikes! As the above poster has stated, I would contact management, and continue to go up the food chain until the issue is resolved! Glad Grandpa has such a conscientious person living with him!

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why are you going out of your way to ruin this guy's career? He's human. He made a mistake. Mistakes happen. IMO, you're trying to make a mountain out of a molehill. When you start working as a nurse and make a mistake, how would you like it if the patient wrote a formal complaint against you to the hospital? It's not a nice thing to do. If it bothered you that much, you could have insisted that he count the pills, or have the pharmacist come over and do whatever it they are supposed to do.

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Specializes in SRNA.
why are you going out of your way to ruin this guy's career? He's human. He made a mistake. Mistakes happen. IMO, you're trying to make a mountain out of a molehill. When you start working as a nurse and make a mistake, how would you like it if the patient wrote a formal complaint against you to the hospital? It's not a nice thing to do. If it bothered you that much, you could have insisted that he count the pills, or have the pharmacist come over and do whatever it they are supposed to do.

How would you feel if the OP wasn't such an honest person, took the narcs for herself, replaced them with some OTC medication, and returned them to the pharmacy? Then, after the pharmacy personnel doesn't check that the returned containers are filled with the proper pills or the proper quantity, the prescription is dispensed to the correct customer. Still a molehill?

Perhaps such a thing would cause a life threatening reaction. Still a molehill?

Or maybe he's a pharmacy tech that is diverting narcs by intentionally giving narc prescriptions to the wrong patients in hopes they will notice the error, return the drugs, and any discrepancy can be attributed to the customer who returned the prescription. Still a molehill?

Whether an honest mistake, or one of my farfetched conspiracy theories, the actions taken by the pharmacy personnel when accepting the returned prescriptions could potentially have devastating repercussions.

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I wouldn't call the name listed on the prescription. I would follow up with the pharm tech's superior to let them know of the situation and ensure it doesn't happen again.

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just as i said before, if it bothered the OP that much, then she should have done something then. not wait and report the guy. just remember, one of these days you will make a mistake, and i hope that your patient doesn't blow it out of proportion like it seems you are doing here.

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why are you going out of your way to ruin this guy's career? He's human. He made a mistake. Mistakes happen. IMO, you're trying to make a mountain out of a molehill. When you start working as a nurse and make a mistake, how would you like it if the patient wrote a formal complaint against you to the hospital? It's not a nice thing to do. If it bothered you that much, you could have insisted that he count the pills, or have the pharmacist come over and do whatever it they are supposed to do.

If "this guy" cared so much about his career; he'd either properly have accounted for the returned meds or if he didn't know what to do, do what I would do: Call his supervisor and ask for help with the proper process. Giving the wrong medication IS a mountain. People can die. Returning medication that has been out of your hands without taking the steps required to make sure ANOTHER person doesn't receive the proper medication IS a mountain as well. As I said earlier; if this guy is so nonchalant when a customer (obviously one who pays more attention than he does) is present, what might he be doing carelessly when nobody is watching? :(

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perhaps he was having a bad day and wasn't focused. we all have those kind of days. maybe he was new and didn't know the importance of counting narcotics. we were all new at some point. thankfully, in this case, nothing bad happened. i just think it's immature to report someone in a case like this, especially when the problem could have been addressed over the counter. i once received the wrong prescription bottle, too. when i got home i looked at the bottle, and someone else's name was on the bottle. i brought it back to the pharmacy, gave it back to the person who gave it to me and told them i was given the wrong medication. he apologized - end of story.

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just as i said before, if it bothered the OP that much, then she should have done something then. not wait and report the guy. just remember, one of these days you will make a mistake, and i hope that your patient doesn't blow it out of proportion like it seems you are doing here.

because this concerned a narc, were talking potential DEA involvement, still a molehill? dont thing so....you REALLY, REALLY dont want to deal with them!

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Specializes in Emergency/Trauma.

Before nursing school I worked in a couple different fast food places. Customers would often bring their bags in from drive through claiming that they got the wrong order. We would get them their order but I would always offer if they wanted the original bag also since I was going to throw it away, and I always did if they didn't want it. Now if I was that careful with a Big Mac, phams or techs should know to be that careful with meds. Be it narc or just Tylenol there is no way that should be reshelved. And as for making a big deal out of reporting him, I would hope if I did make a mistake that stupid someone would report me so I would know how serious it is and you can bet your bippy I would never do something like that again. We learn from our mistakes but if no one points them out how do we know they are mistakes?

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