Watch your meds CLOSELY! (long)

TazziRN, RN · Apr 25, 2007

Don't be too hard on the ER staff. We know the names of meds and what they do and for some, even the dosages, but we do not know what they look like. Norvasc and Monopril are not drugs given in the ER so we would have no reason to know what they look like.

I'm glad it was caught before the mistake was fatal, I hope your grandmother improves.

santhony44, MSN, RN, NP · Apr 25, 2007

The pharmacy I use has started including a description of the pill on the outside of the bottle. "This an oval orange tablet with ER123 on the side." I think it's a great idea and I hope it spreads.

kittagirl · Apr 25, 2007

That is a brilliant idea, so easy and simple, hopefully it will spread.

The pharmacy I use has started including a description of the pill on the outside of the bottle. "This an oval orange tablet with ER123 on the side." I think it's a great idea and I hope it spreads.

MedSurgeNewbie · Apr 25, 2007

This is going to sound goofy but when my gran was with us, she took 15 meds - I took digital pics off my online PDR you could just use a camera and made a little key as to which pill was wich- there was so many that I need a little chart - might help - I love that idea that some places are including a discription on they bottles that is very cool -

justme1972 · Apr 25, 2007

When I hear about stories such as this...I wonder with how many of these med errors at the pharmacy are done by the pharmacy technician instead of the actual Pharmacist.

herecomestrouble · Apr 25, 2007

Recently I had pnuemonia and my Dr ordered a ZPac,I sent my son to pick it up for me and he came back with acyclovir.I called the pharm and their excuse was that the ZPac wasn't ready but the acyclovir was so they just sent that.Really strange since it had been 6 months since the last time I had shingles.Now I open all my meds at the pharmacy before I leave,I may not recognize every pill there is but I do know what mine look like and since there are no generics for what I'm on there are no surprises.

At work I got a med delivery and one box marked Prozac was full of Pepcid.

swatch007 · Apr 25, 2007

Interesting posts. I have read many medication errors on discussion forums, online news and nursing journals, but I have never get tired of reading them. They are all scary because they imply that anybody could easily make this kind of mistake as fatique, busy unit, unbelievable workload. and other factors that could contribute to human error are increasing nowadays.Sadly, one serious mistake can abruptly change a nurse's life, will be left at the mercy of BON and employer. Of course, our greatest concern is the effect of this error on the patient who trusted us.

I couldn't say better myself,so I'm just going to repeat the title of this post, "Watch your meds CLOSELY!!!"

Rudegal2020 · Apr 25, 2007

Sooo sad but it happens all the time. 20/20 had a big story about that sometime last month about walgreens and a another pharmacy med errors.

One mother picked what she believed was dilatin but was given metformin for her 2year old daughter, sadly the baby went into a coma and has had retardation ever since. She sued them for millions and won but that neve replaces her child having a normal life.

nurturing_angel · Apr 25, 2007

Hubby and I went to get my prescriptions filled one day. He went in and I stayed in the car as I was not feeling well. He returned to the car with a HUGE bag of medicine bottles. Now I take a lot of meds d/t my heart disease and diabetes and sometimes the bag is large. But for some reason, I felt the need to check this supply out. He is backing out as I am fishing around in the sack and pull out a big ole bottle of Methadone.....I don't take Methadone. This bottle has someone elses name on it. STOP! I take it back in. The pharmacy tech is slobbering all over me thanking me for discovering the mistake and returning the bottle which she had picked up mistakenly and placed with my meds. Thank goodness she mistakenly put it in my bag of meds instead of someone thinking about the street value of methadone. Sheesh! What a costly and potentially deadly mistake!

:balloons:

kukukajoo, LPN · Apr 25, 2007

It is frightening that this is happens at all and some cases are very sad.

The pharmacy I will use from now on does the pill ID with a picture and description but the other one did not. This med is a new generic so there is no photo up on any of the websites that I have found, not even the manufacturer has a pic! To make it worse, the norvasc has a big M on it that I assumed was for monopril (nope- it's the manufacturer's initials!).

Tazzi- I don't blame the the ER or anyone at the hospital, including her doc who reviewed her meds with me then. I don't know if this error would have even been caught if the dosage hadn't been halved and she actually had some left to compare to!

What I will do from now on: Keep meds at my house, Check EVERY bottle upon receipt from the pharmacy with one or more visual identification techniques, verify the dose is correct, etc. I will do this with ALL meds from now on with everyone, not just my grandma, but being I love her so much I can't be too careful! I am not prepared to lose her yet!

TazziRN, RN · Apr 25, 2007

Recently I had pnuemonia and my Dr ordered a ZPac,I sent my son to pick it up for me and he came back with acyclovir.I called the pharm and their excuse was that the ZPac wasn't ready but the acyclovir was so they just sent that.Really strange since it had been 6 months since the last time I had shingles.

That is just plain stupidity....that's a pharmacist who should not be practicing. I quit going to our Wal Mart pharmacy because there was one pharmacist who kept screwing with my scripts. On one he misinterpreted the doc's order, even though it made plenty of sense to me, and he argued with me about it. I finally told him to call the doc (which he should have done as son as I questioned it) and I was right. Another time my doc wrote for neb solutions. I picked up the package, didn't look in the bag, drove home (20 miles away in another town), and found two boxes of MDIs. When I called instead of saying "I'm sorry, I messed up, come back and I'll fix it," he argued with me again that the writing wasn't clear. Did he call the doc? NO!!! He looked in the computer at my med history and found that I had had MDIs filled in the past, so that's what he gave me!!! That was the last straw, and there were several incidents in between the two. I notified the head pharmacist, the store director, and the regional office, and I told the pharmacist to his face that the mistakes he had made with me were reportable to the state, and I told him that if he didn't quit making them that someone would.

I wish I had, in retrospect.

santhony44, MSN, RN, NP · Apr 25, 2007

I notified the head pharmacist, the store director, and the regional office, and I told the pharmacist to his face that the mistakes he had made with me were reportable to the state, and I told him that if he didn't quit making them that someone would.
I wish I had, in retrospect.

It may or may not have done any good.

My husband was on carbamazapine. We had moved to another state but were getting our meds from a pharmacy where we'd moved from. His carbamazapine got delayed in the mail, so I got a script from the physician I worked with and my husband took it to a local pharmacy.

He got the meds, went home, and took a dose. He called me a little later at work, slurring his words so badly I could hardly understand him. I had to borrow a car from the office manager, go home and check on him, pick the kids up from school (he usually did that), then later have my 15 year old son with a learner's permit drive my car to pick me up.

My husband was basically out of it for 3 days and didn't feel like himself for 3 or 4 more.

His med bottle had "carbamazepine" on it. The pills inside were brown. He'd always had white before, but generics can change, right?

I finally called my pharmacist friend out of state and told him what happened. He'd never seen carbamazepine in any other color but white. He did a search on his computer and told me that it's not made in any other color! "I don't know what that pharmacist gave you but it was the wrong med." I went to the pharmacy and put the bottle on the counter. The guy looked at it, set down a stock bottle of chlorpromazine, then before I could stop him, dumped the pills from my husband's bottle back into his stock bottle! :angryfire

After I left the pharmacy, he denied ever giving my husband the wrong med. My pharmacist friend about had a fit when I told him; he told me that a mistake like that would have been called a "kill" when he was in pharmacy school, and that it would have failed anyone.

After the pharmacist denied ever giving the wrong med, I did report him to the state pharmacy board. Many months later, after we had moved away (back to where we were before) I got a letter saying they'd investigated and didn't find anything. Well, of course not, he destroyed the evidence then lied about it. I hope that it will still be on his record that he's been investigated, so that if it ever happens again action will be taken. I also made sure the doctors I worked with and the administrator of the hospital knew exactly what had happened.

I would still swear in court as to the pharmacist's actions. He was, BTW, the owner of the small pharmacy and my next door neighbor at the time. I can't tell you how many times I mentally flattened his tires!! :trout: If he had acknowledged his mistake and had even once walked over to check on my husband's status, I would not have reported him.

In case anyone's wondering, the med my husband got was generic Thorazine- and a whopping big dose at that. :angryfire