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!

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.

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

Critical thinking, in my opinion, also means taking into consideration the near-misses and the "what if's" and learning from this. While this may mean being a drama queen, it's still critical thinking in my opinion.

Give me a nurse with that style of critical thinking rather than the one with the flippant "oh well he didn't die, no big deal, o.k. to blow of this potential problem/error/mistake" type of nurse any day.

Tempest in a teapot.

I had a very common maiden name. I once got someone's else's medication, same name. I read the label, said to myself, "Hey, I'm not on this" and brought it back. They gave me the right ones. I actually never thought twice about it.

Stuff happens. I guess I'm somehwere between drama queen and blow it off.

Specializes in Vents, Telemetry, Home Care, Home infusion.

The bigger issue here is: LEARNING from the mistake, so it won't happen again.

We often learn MORE from our mistakes than we do from our successes. With serious issue like this, it is important to go up one level in chain of command in order to

a. document occurrence to prevent it getting swept under the rug

b. Manager on notice issue with an employees practice: verbal counseling can be given----

or maybe it's 3rd time problem giving out similar persons meds occurred and termination needed

c. Good manager can then observe if individual practice problem or system issue and re-education needed to entire pharmacy staff.

d. One ounce of prevention is worth pound of cure.

Similar issue happened with my husbands BP med few years ago---totally wrong med dispensed. Manager was grateful it was reported as repeat incident and entire staff needed to be addressed, some replaced.

Specializes in Community Health, Med-Surg, Home Health.
Tempest in a teapot.

I had a very common maiden name. I once got someone's else's medication, same name. I read the label, said to myself, "Hey, I'm not on this" and brought it back. They gave me the right ones. I actually never thought twice about it.

Stuff happens. I guess I'm somehwere between drama queen and blow it off.

I fall in line with you, Susan. I do believe that the pharmacist definitely needs made to be aware in order to correct the situation, and I can see the implications of what could have happened to the patient. What we need to keep in mind, however, is as long as the human factor is involved, mistakes can and do happen. And, I also know that while it may be voiced that facilities want to invite people to share their mistakes for learning, say that they are not punitive, etc...reality is that people are treated subjectively. Some are comforted and told that they are forgiven and then, there are others that are literally crucified for less. Many of us here can attest to preferential treatment based on who are the favorite children of the right people. I support a more moderate approach, myself.

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.
Tempest in a teapot.

I had a very common maiden name. I once got someone's else's medication, same name. I read the label, said to myself, "Hey, I'm not on this" and brought it back. They gave me the right ones. I actually never thought twice about it.

Stuff happens. I guess I'm somehwere between drama queen and blow it off.

You did point out the error to the pharmacy and hopefully they learned from it, so you didn't blow it off. No need to be a drama queen either running to their boss "I could have died!!". But a critical thinker does see the potential for harm in near-misses and learns from them.

Specializes in ortho, hospice volunteer, psych,.
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.

I certainly hope you aren't involved in ANY aspect of patient care or work behind the pharmacy counter because you would be unsafe. Many people -- elderly and others -- don't bother to check their meds because they just assume they're safe to take and are the meds they were supposed to get. Don't be so flip because the error could affect your family member and possibly be fatal. Then how would you feel about it?

Specializes in Med/Surg, Home Health.

Death is a possibility with such errors. You need to realize that allergies are serious business and if the OP had not checked the Rx, this could have happened to grandpa. No, it didnt happen, but the next customer may not be so fortunate. And if death ever occurred because of the pharmacy tech's mistake, Im sure he/she would have wished then that the mistake had been brought to their attention beforehand. I would rather be corrected BEFORE something bad happens than to feel guilt and sorror for a mistake that cost someone their life.

Specializes in Telemetry & Obs.

I think had the pharmacy tech handled the situation professionally the OP wouldn't be posting about it. It was his cavalier attitude that prompted this thread.

Yes, mistakes in healthcare do happen. It's how they're handled afterwards and hopefully prevented that makes the difference.

Specializes in nursing student.
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.

Point is, something bad could have happened. Thankfully it did not in this case but had the OP not checked prescription bottles it could have. I would hate to be a person in your care if you have such a cavalier attitude about the well-being of others when it comes to improoperly dispensed medications.

I'm confused....if the medication was still in the bag then didn't it have your grandfather's name still on it?? So what would be the point of putting it in the customer pick-up bin? Is there any chance that bin was for returned items, etc and that the medication would be verified later?

I probably would let the pharmacist know of my concerns, but I wouldn't call the other customer for sure. That violates his right to privacy.

Just to clairify - The bag was labeled with the other customers name on it, along with the other customers name on the pill bottle as well.

A red flag should have went up when pops picked up the meds, because they were two different bags (usually, it's one bag, two meds inside and two stickers on the bag).

Specializes in Maternal - Child Health.

Interesting reading which may be enlightening for posters who believe that pharmacy errors are no big deal:

http://www.op.nysed.gov/pharmcounseling.htm

The following are actual cases of medication errors reported to the State Education Department. Some involve sound-alike and look-alike drugs. These errors may have been identified and avoided through counseling or through a more thorough review of the patient profile:

* A six-day old infant received 35mEq of Potassium Chloride, rather than the prescribed dosage of 3.5mEq. This error had a fatal result.

* An elderly patient stabilized on Coumadin 1 mg daily received a new prescription for continued therapy at the same dose. A pharmacist mistakenly filled the prescription, providing for 6 mg daily. The pharmacist did not review the patient’s profile, and did not provide the required counseling to the patient on what would have been a change in dosage. In retrospect, the prescription was clearly written for 1 mg. This error resulted in several days of unnecessary hospitalization for the patient, and is but one of many recent errors reported involving this drug.

* Several infants received Zyrtec liquid rather than the prescribed Zantac liquid. There is no indication for Zyrtec in this population. As a result, the desired therapeutic response was delayed. This situation resulted in a number of unnecessary trips to the physician and caused great concern to the parents.

* A non-diabetic patient received chlorpropamide rather than the prescribed chlorpromazine. The patient sustained permanent impairment.

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