Watch your meds CLOSELY! (long)

Nurses General Nursing

Published

Has this ever happened to anyone? A med error caused my gram to be hospitalized and we are lucky!

Well today I ran to get my gram's Norvasc filled. They fill it with generic- No big deal Right? Well I get to her house (she is on 4 meds total- not too hard to keep track of).... I get back and am organizing her pill box and notice that she has it all screwed up..... Trying to sort through her meds I realize the Norvasc I just filled has the SAME exact pills as the Monopril I filled on 3/14/07. ***? I am thinking that the pharmacy made a mistake TODAY since it has a M on it and matches the other bottle, etc. i then realize the meds in the monopril bottle from last month are actually generic Norvasc and that the script from today is correct. She had been taking double norvasc and NO monopril for a month! It was not caught sooner as she had been taking the name brands which are not even shaped or colored the same.

The pharm error was made on 3/14/07. she was hospitalized 3/15/07 for bradcardia and afib, irreg heartbeat. hmmmmm any connection ya think?!?!

Now gram is 86 but me as an average functioning nursing student it was sooo confusing to me I can't imagine that she would have ever figured it out. The hospital did not even catch it, as I had brought every pill bottle in.

I finally just filled her weekly pill box and took home the rest of the bottles- I will fill them weekly for her, although sad to say I trust her more than I trust the pharmacy right about now.

I guess the moral of the story is to be very very careful when working with seniors on meds and try to be consistent with the brands, manufacturer, etc. to prevent errors from happening.

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Specializes in med/surg, telemetry.

Very good advice. I'm just sorry that it was learned in such a difficult way. I hope that she is recovering well from the mistake!

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Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

She's lucky she has you. What a hard lesson to learn.

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She seems okay but is still having issues, some kidney failure and still afib and bradycardia. But then today she had a double dose, and non-dose. Tomorrow she will have the correct dosage of both meds for the first time in more than a month. She has had considerable muscle weakness and I think this is why now, and not just her age and other probs. I PRAY she gets better soon as the weakness has been so pronounced she has been housebound other than when I force her out with her walker to keep her somewhat mobile.

At the same time I am upset with the pharmacy for making the error and more so with me for not catching it sooner- here I am a student who just went over ALL those meds and I did not catch it at all. What kind of nurse am I going to make? I can promise you I will ALWAYS verify the appearance of a pill either with the printout or by a book and if the pharmacy does not provide the printout with the appearance picture, I will request it every time. I am switching pharmacies and will just have to be extra vigilant I suppose. I feel so awful!

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I pray that she feels better soon.

Good dective work

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Have you talked with the pharmacy yet? I was on the receiving end of the med error and got serzone instead of seroquel. Screwed me up a bit. When I swiched back to the seroquel, I went through the DT's. Wasn't fun!

Hope she gets to feeling better.

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We had a huge pharmacy error i no here ini the town I live in that ended up with a kid being shipped to a PICU. The child takes Ritalin and was given Methadone instead. Thank God he only got one 10 mg. pill but this guy is only 8 years old.

You can't be too careful cause we are all human and subject to making mistakes.

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At the same time I am upset with the pharmacy for making the error and more so with me for not catching it sooner- here I am a student who just went over ALL those meds and I did not catch it at all. What kind of nurse am I going to make?

One who is only human and learns and grows from her mistakes.

Hope all is well with your Gram, and try not to be so hard on yourself. After all, you did find the mistake. Somebody else might not have.

Best regards

~Wave

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The pharmacy near my house is always screwing my meds up. One time I thought I was taking zyrtec and was actually taking zoloft. I couldn't figure out why my heart was racing...then I figured out by looking in my drug book they filled it with the wrong prescription.

Just recently I had a antibiotic filled, it was suppose to be only 20 pills. No joke they gave me 120 pills. The best part was there was 3 stickers on the bottle to "make sure you take all pills, do not stop without consulting your doctor".[EVIL][/EVIL] I'm just glad I'm educated on this stuff. If they are messing up my prescriptions who knows what else they are doing.

I'm glad you noticed they mistake and hopefully you're Gram is getting better.

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good thing your gram has someone like you to look out for her and i hope she is feeling better and good catch.

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Specializes in Lie detection.
She seems okay but is still having issues, some kidney failure and still afib and bradycardia. But then today she had a double dose, and non-dose. Tomorrow she will have the correct dosage of both meds for the first time in more than a month. She has had considerable muscle weakness and I think this is why now, and not just her age and other probs. I PRAY she gets better soon as the weakness has been so pronounced she has been housebound other than when I force her out with her walker to keep her somewhat mobile.

At the same time I am upset with the pharmacy for making the error and more so with me for not catching it sooner- here I am a student who just went over ALL those meds and I did not catch it at all. What kind of nurse am I going to make? I can promise you I will ALWAYS verify the appearance of a pill either with the printout or by a book and if the pharmacy does not provide the printout with the appearance picture, I will request it every time. I am switching pharmacies and will just have to be extra vigilant I suppose. I feel so awful!

Some advice from a visiting nurse:

Definitely talk to the pharmacy and bring the bottles in to them so they can see them.

Also keeping meds at your house is a good idea. I have had my pt's putting pills into different bottles often. It's not always the pharmacy. Sometimes pt's are forgetful or think they are helping.

For future reference,there's a website where you can enter the inscription on the pill and pill shape and it will tell you what the pill is, manufacturer and show you what the pill looks like as well for comparison. If you want a link, PM me.

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Once upon a time I worked in a Pharmacy... an extremely HIGH volume retail pharmacy (1800 rxs daily) and we made maybe 4 documented med errors a YEAR. Now there should never be mistakes made in my opinion because we are talking life and death. But if you know of a Pharmacy that makes multiple mistakes I would honestly report them. To the public who is uneducated, someone might die because of these mistakes. Thats my 2cents anyways.

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