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Would you have done the same? Recieved wrong prescription.

Posted

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!

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?

kmoonshine, RN

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.

NurseKatie08, MSN

Specializes in Geriatrics, Transplant, Education. Has 12 years experience.

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!

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.

Reno1978, BSN, RN

Specializes in SRNA. Has 6 years experience.

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.

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.

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.

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? :(

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.

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!

Hilinenursegrl

Specializes in Emergency/Trauma. Has 1 years experience.

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?

I would follow up with the pharmacy manager at that store, so they can directly address it with that specific employee. Or maybe they'll call a dept meeting and address it with everyone. Sometimes things are skipped in training. Sometimes mgmt assumes people know how to do certain things, because mgmt knows how to do it. But thats not enough. Unless this is one of a long list of "mistakes" and carelessness on the employee's part, they're not going to lose their job over it. Mgmt is just going to say "Hey, need you to be more careful...we had an incident and this is what happened. This is what SHOULD happen, please make sure you do this next time" and explain it.

And they WILL address it, because they don't want to get sued by someone who dies from the wrong medication the next time it happens.

Purple_Scrubs, BSN, RN

Specializes in School Nursing. Has 8 years experience.

I threw a fit when the Vet gave my dog the wrong med - oh yes, I would be filing complaints if it was my family member!

I don't know that I would call the guy whose name was on the script, though. If some random person called me and told me that, I would feel weird that now this stranger knows all about my meds (especially a narc). In your complaint you might mention that you feel the right thing to do is for the Pharm to call him, but there is no guarantee they will, of course.

Jolie, BSN

Specializes in Maternal - Child Health. Has 34 years experience.

maybe he was new and didn't know the importance of counting narcotics. we were all new at some point.

Pharmacy techs must complete training before they can work in a hospital or retail setting. This guy wasn't fresh off the street and unaware of state law and employer policy and procedure regarding handling of medications, especially narcotics.

Mistakes do happen. It is the inappropriate and non-nonchalant way this employee responded to the mistake that rightly raised concerns, and needs to be addressed for the safety of the public.

truern

Specializes in Telemetry & Obs.

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.

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.

minnie82

Specializes in Telemetry.

I used to work in a pharmacy as a tech for two years.

The training isn't as intense as it may seem as I got my certificate through work. However, at the chain I worked at, there were several extensive tutorials/programs that everyone had to complete to avoid these kinds of mistakes.

You should definitely contact the pharmacy manager as well as the district manager for the chain. If the prescriptions were in the same plastic bag, the pharmacist that approved the meds may be cited for the mistake.

From my knowledge, any meds that are taken out of the pharmacy may be no longer be dispensed. They should be disposed of by the pharmacist in charge in case of tampering.

I don't think you should contact the person on the prescription bottle. The pharmacy manager may be able to cover up the mistake but if you contact the district manager as well as filing a formal complaint with the chain, you can be sure someone would be held liable.

You're grandfather is very lucky to have you take care of him. There is a chance that he might have not caught the mistake and would currently be taking an additional narcotic.

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.

Wow, I'm blown away by this post.

If I screwed up this bad I deserve to have it bought to my attention. Some complaints patients or family members submit have no merit. This kind of complaint holds great merit.

My bil is a pharmacist. I sent him a copy of this thread. He had some great points:

1-The first comment he made was the pharm tech should have asked the pharmacist to speak with the customer and never handled that situation himself.

2-The pharmacist would have disposed of the meds. He/she would have no idea if the meds had been tampered with.

3-The meds cannot be resold. In this country, we do not even recycle the bottles prescription meds are given to the patient in. In some countries you can take your bottles back to the pharmacy to be recycled!

4-He also commented it put a red flag up for him that the tech took care of this, not turning it over to the pharmacist. Either this pharmacy is being run by shoody people who in turn have shoddy work ethics or the tech is perhaps filling scripts that a tech is not legally allowed to fill. He said this does happen. Pharmacists will let techs fill narc scripts and the pharmacist "just signs off". But a narc has to be visually assessed and counted by the a licensed pharmacist. Perhaps the tech filled this, realized he/she screwed up when the customer came back and was able to bury the whole situation.

As a consumer I would greatly encourage you to proceed with contacting the home office of this chain pharmacy. And get the names of those who were involved. Yes, screw-ups happen, But they are also the driving force that makes us each better at our jobs. Imagine losing a family member because they were unable to understand they had been given the wrong med. (by not reading the info on the bottle or just assuming this is the med they are to take.) Scary stuff. We have to work hard to protect the license we have earned. It didn't come out of a Cracker Jack box. In my opinion that tech is putting the pharmacist's license at risk by not informing them of the situation. Imagine how we would feel if a nurse tech covered up a dire situation or "just handled it" without reporting to the nurse they work under. The ramifications are many.

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