Pharmacist mistakenly gives woman wrong pills
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SEATTLE -- A local woman said she's learned a lesson after a scare with her prescription medication, and now she has a lesson for everyone else.
Sandra Herrera suffers from multiple sclerosis and recently had surgery on her hip. She's now on several medications, but she realized one of her prescriptions is not what the doctor ordered.
Herrera said it was a subtle difference in color that tipped her off that she was given the wrong pills.
"I just happened to read this really small print that describes the pill," she said.
The pill was supposed to be a 250 milligram capsule. It was supposed to be white and green and have the numbers 293 on it. Instead, she found a 500 milligram capsule that was light green and dark green and had the number 294 on it.
Herrera had been taking a double dose for two days.
"My doctor prescribed this amount because he knows all the medicine I take for my MS, so how do I know if those two days did something to my liver. I may never know," she said.
The label on her prescription was correct, but a Rite Aid pharmacist gave her the wrong dosage.
"Why don't they have protocols that check, do a double check to make sure this is right before it goes to the customer?" Herrera said.
In a statement, a Rite Aid spokesman said there's a seven-point check for accuracy before each prescription leaves the pharmacy. The company is now investigating to see if that procedure was followed.
The statement reads, "Patient safety is a top priority for us. Rite Aid takes all complaints including this one very seriously, and we work very hard to ensure accuracy."
The pharmacy apologized to Herrera, but she said she will get her prescriptions elsewhere from now on.
"It only has to happen to me just once," she said.
As part of Rite Aid's investigation, local management is speaking with the pharmacy staff to make sure they follow training procedures.
Sandra Herrera suffers from multiple sclerosis and recently had surgery on her hip. She's now on several medications, but she realized one of her prescriptions is not what the doctor ordered.
Herrera said it was a subtle difference in color that tipped her off that she was given the wrong pills.
"I just happened to read this really small print that describes the pill," she said.
The pill was supposed to be a 250 milligram capsule. It was supposed to be white and green and have the numbers 293 on it. Instead, she found a 500 milligram capsule that was light green and dark green and had the number 294 on it.
Herrera had been taking a double dose for two days.
"My doctor prescribed this amount because he knows all the medicine I take for my MS, so how do I know if those two days did something to my liver. I may never know," she said.
The label on her prescription was correct, but a Rite Aid pharmacist gave her the wrong dosage.
"Why don't they have protocols that check, do a double check to make sure this is right before it goes to the customer?" Herrera said.
In a statement, a Rite Aid spokesman said there's a seven-point check for accuracy before each prescription leaves the pharmacy. The company is now investigating to see if that procedure was followed.
The statement reads, "Patient safety is a top priority for us. Rite Aid takes all complaints including this one very seriously, and we work very hard to ensure accuracy."
The pharmacy apologized to Herrera, but she said she will get her prescriptions elsewhere from now on.
"It only has to happen to me just once," she said.
As part of Rite Aid's investigation, local management is speaking with the pharmacy staff to make sure they follow training procedures.
It is unfortunate that this medication error occurred. However, one positive to come out of this is that it was an antibiotic, which is highly unlikely to have serious adverse effects. Pharmacists are still humans after all and mistakes can happen. Sometimes medications from different manufacturers are dispensed and can have different physical characteristics. It is good that patients are taking a pro-active role and reviewing their medications with their pharmacists before administration.
I had a pharmacist give me the wrong script once but thankfully noticed it before I left the store.Â
A few points:Â
- Yes, Rite-Aid totally messed up by dispensing the wrong dosage, and congratulations to the patient for being cautious and careful enough to identify the mistake and bring it to the pharmacist's attention.
- However, how about writing and producing the segment with more information before you scare the crap out of patients everywhere. The drug was an antibiotic which was most likely being used to prevent post-op infection. Common adult dosing is 1000mg - 4000mg/day, dosed every 6-12hrs. Doubling the dose for 2 days is highly unlikely to have serious consequences. If you are the patient and this happens to you, why not call your doctor and let him or her know what happened? Her MD could easily assess if her health was put in danger and order appropriate tests rather than her wondering + worrying if her liver was damaged. Simple LFTs could immediately assess for liver injury.
- As others have pointed out, the medical establishment makes mistakes. Have the pharmacist show you the pills every time at the counter and have them explain why/for how long you'll be taking the drug. Do what this patient did: Read the fine print. Use online pill identifiers and pictures if you have to.
- Please keep an up to date list of your medications and all supplements in your purse, wallet, smart phone or glove box. Know the name, type (immediate release vs. extended release), dose and timing and what it's supposed to treat. Also keep a list of allergies + the type of reaction that you experience. This can be a lifesaver in a medical emergency or unexpected hospitalization or new clinic visit where providers need to know exactly what you are taking. Don't forget over the counter supplements too like herbs as they can interact with your meds.
@Soleena It's okay to "scare the crap out of patients everywhere" if it saves one person from a serious drug mistake. I was hospitalized because my bp was 60/40 -- due to a new medication. Upon leaving the hospital, I picked up my substitute medication from the hospital pharmacy. The pill was red, and I thought it looked just like the pill which had led to my crisis. I was right; the correct pill was orange, as I had thought. Fortunately for me, I recognized this error. But sometimes these pharmacist errors CAN be serious.
No comment. Been there - done that. Twice. I'm happy where I go now, but I always, always double check what I'm given!
I've worked in healthcare for decades. I can tell you I've seen so many errors from doctors, nurses, MA's, PA's, pharmacists, nurses, ARNP's, patients themselves, etc. Some lethal. As many have stated, the best bet is: do not take meds blindly. Do not give meds to your loved ones blindly. And that goes even deeper with deciding whether or not medication is really what you need. If it is, fine, then be an informed consumer. To blithely believe that doctors and pharmacists know all is dangerous. They are human and make mistakes - obviously.
MR GOWER!!!!!! MR GOWER!!!!!!
Eat more vegetables and fruit along with whole foods.  Avoid processed food and food made with GMOs and exercise regularly and you will never have to fill a prescription. Â
The industry is just a huge cash grab. Â Take care of yourself and you don't need them.Â
@The206 I'm not sure vegetables will cure MS. Although this script was for an antibiotic the woman did say she is on a lot of meds for MS.
@The206Â Wow, that's a really naive viewpoint. What if you get e-coli from contaminated fruits or vegetables? Just eat more and it'll all go away?
@The206 Right, pray that staph infection away! Flesh-eating bacteria? A carrot a day will take care of that!
@The206 I fully agree with you, if you live healthy, you'll avoid this. But it takes a lot of work and that is not always what people want.
This is front page news, really?Â
Always check if you can.On a new prescription you donât typically know what the pills look like until you get them.Read all the paperwork and listen to the pharmacist.They should talk to you about new medications.On refills, if anything looks different, shape color, size, call the pharmacy or return and talk to them.It would be nice if no one ever made a mistake, but we humans are not perfect and that is just life.Be proactive, especially with your health.
One time at the drive thru at McDonalds they gave me a cheeseburger instead of chicken mcnuggets. Â
@70MonteCarlo That is an absolute travesty! Thank God you are even here to type about it and I can't even imagine the hell you've gone through that day and every one since.Â
I certainly hope you followed the lead of the tragic, yet brave young woman in yesterday's headlines, who was cruelly, heartlessly deprived of eating her smelly breakfast sandwich on the bus: did you scream and swear and berate the employee who tried to destroy your life? Did you complain "at the city, county and state levels" and demand justice?Â
I had a prescription filled on Saturday at Walgreens. The bottle and the supporting documents said the pill was round and red, yet the pills were round and green. I went right back into Walgreens and asked why and they said they had to use a different manufacturer. I still felt uncomfortable because the documents they provided me should have been for the manufacturer they filled the prescription with, not what I received the last time I was there. I am still uneasy about it, hopefully I don't overdose on iron!
@Michelle You can search just about any supplement, or over-the-counter or prescription and see several images of the various strengths and brands.Â
Iron is relatively innocuous when used correctly, but can lead to some serious problems if you used too high a dosage for awhile.Â
Always read the information that comes with your prescriptions and check the pills. This is more common that people think. I will not take anything until I understand what it does and what side effects there will be.
@luvnstuff2Â Impressive. I'll bet you had good staffing. It makes a difference, and Rite Aid has some of the worst staffing in the industry ( Worst in the sense of how many staff they have at any one time) This comes from top management who are more concerned about operating expenses than patient safety.
@rx30Â @luvnstuff2Â I would NEVER get a prescription filled at Rite Aid for this very reason. Â Having worked for them, the conditions that the corporation puts on pharmacist with staffing are downright dangerous. Â They are at 25% understaffed. Â Rite Aid is concerned about their bottom line, not your safety. Â The Pharmacy District Managers are "Yes men (and woman)" to the corporation. Â They are not working to improve the severe issue Rite Aid has with under-staffing. Â That should have been part of Kristen Drew's story. Â There are plenty of ex-Rite Aid pharmacists and technicians that could back that part of the story up.Â
@JCCBlvu @rx30 @luvnstuff2 Good to know!
I had a situation where I was depressed over my mom's death. Was put on prozac. After several weeks it wasn't helping and I was having side effects that were difficult to tolerate. Family doc sent me to a psychiatrist who, after taking history, gave me samples of serzone. She did not tell me to stop taking prozac. After a couple days I could neither speak nor write (I could type oddly). My wife called the pharmacy where my prozac was filled and the pharmacist told me to stop taking prozac with serzone.Â
Mistakes can be made and in the medical field there are a lot of places in the chain for mistakes. In most cases your pharmacist is better able to detect and find errors doctors make in prescribing meds than another doctor is.Â
Still it is good to check things out. My lesson learned was when a doctor gives you similar meds or samples ask about the ones you're already taking and check with your pharmacist (if you have one) who knows your history -- and dont go to multiple pharmacies unless necessary. If you get new pills you're unfamiliar with check them out online. webmd has a pill finder. Also, some pharmacies will put the shape, color, and imprint of the pill on the label or monograph (that little paper that comes with the pills) so you can double check.Â
Also read the prescription your doctor gave you and make sure you understand the prescription from the doctor as well.
@Nic Stevens Well you also have to be more inquisitive about your own medical care. A reasonable person would have asked about the other drug, when getting a new one. Seems pretty common knowledge that you wouldn't be taking two of those types of pills at once.Â
@DTÂ @Nic Stevens Actually it is not common for laymen to know this! The danger is when you go to different physicians, the two do not know what other meds you are on. Plus, your own doctor's office rarely will actually update your med list in their records. So NEVER assume they know what you're taking. I see it ALL the time.
I picked up one of my scripts from my pharmacy, and noted they looked a bit different. So, I looked them up with the info that is on the pill itself, sure enough, they were the wrong pills... Did I scream and whine about it? nope, just took the meds back to the pharmacy who exchanged them for the correct meds.. (I was more concerned with who got my meds.. because mine were for alergies, not something serious..)
Errors do happen, processes are put in place to minimize the possibility of an error, yet even with those in place, an error can happen.
This is too easy to solve. Â Its time we take humans out of this business and computerize it all. Â
@marvin Yeah, there have never been errors in computerized systems </sarcasm>. I got the wrong meds at UW Hospital. Their meds are dispensed by computer but somewhere in the chain there is a human. As with anything else it is always best to check what you get from someone. Whether its pills, food, computers, cars, etc.
Nothing will ever prevent a human error. The major advances will set up a system that is almost perfect, and Rite Aid, nor any other pharmacy has it. It would involve far more than 8 checks, and involve far more than a person checking another person. I know that I set up a pharmacy with a 5 to 10% error rate when I arrived, and an error rate of 0.00000001% when I left 8 years later. We dispensed approximately 1,000 Rx's daily from January 2007 to May 2010 when I retired, with no reported pharmacy errors. But, there is always the possibility.
Waiting on the grocery store story about getting the wrong item in ones bag...
Considering all of the similar stories, I wish I took my vicodin prescription there...
i caught a mistake just last week - i always check the Rx BEFORE leaving the store. i was rather vocal about it - as it could have been a serious mistake for me. i refused the Rx and transferred to another pharmacy.  Doctors make errors, nurses make errors when calling in prescriptions, pharmacists make mistakes - the onus is on yourself to know what you are taking, what it is for, how it is spelled (many drugs are very close in spelling) and to make sure it is correct. Mine was a compounded formula from a new pharmacy that claims to compound. i was talked into trying them because they were less expensive - I went back to my regular very well trained and professional compounding pharmacy. Cheaper is not always better - ya get what ya pay for sometimes ! it could have been avery bad outcome.
Fred Myers gave my daughter someone elses meds. Pretty scary when they call 3 days later and say...I think we gave you the wrong meds, stop taking them. Only way they knew was when the person whom the meds were intended for came to pick them up. Double check your meds, pharmacists are human.
@FED__UPÂ Yeah, you would think people would actually read what they're getting. Â I do. I check the dose, the name, etc.Â
Something similar happened to me years ago.  The Rite Aid pharmacist gave me the incorrect dosage on one of my high blood pressure medications.  It took about a week for me to realize something was wrong.  My blood pressure was up, my eyes hurt and I didn't feel well (I have VERY high blood pressure - stroke level when untreated).  I finally looked closely at the pills and realized the dosage was half of what I was prescribed by my doctor.  The bottle had the correct dosage though.
I notified Rite Aid who refilled the prescription correctly and then I immediately switched to another pharmacy. Â I've never trusted Rite Aid since and as a matter of fact I won't even shop there.
I can see how this can happen if you consider all those pills they have to work with along with the human factor thrown in. Luckily, it is such a rare occurance since most pharmacies have systems in place to help prevent this. I'm glad the pharmacist I use has the description of the pills we take (color, size, imprints, etc.) printed directly on our prescription bottles so we can double check them ourselves when we get them. Luckily, I've never been given a wrong prescription, but do know of a couple instances where it has happened to people I know.
All the processes in the world can't stop people from making mistakes. Â We're all people, and people make mistakes from times to time. Â Make sure to double check everything you get from the pharmacy before you take it.
This is exactly why I take the half a second to look at my pills when I get my refill and make sure they're accurate.
Pharmacists and their assistants are dealing with so many prescription fills and type, sizes  and varieties of pills it's gotta be mind boggling.
I have been a pharmacist for 30 years and can tell you that this type of error occurs in every pharmacy, at some point. A typical chain pharmacy fills 300-900 prescriptions a day. Often by one pharmacist in a 12-14 hour day. If there is one error every 3 months, that amounts to an error rate of .002%.Pretty damn low in any other industry. What you need to be far more concerned about is if your doctor prescribed the correct drug/ dosage in the first place. This happens far more often, and is that pharmacist who maybe makes 1 or 2 errors a year that catches it. I can also tell you that when the pharmacist who made the error ( I don't even work for Rite Aid) called the patient's doctor so that he knew what dose she actually took, and probably gave her a refund or a gift card in way of apology, or refused the charge to her insurance company. And of course corrected the mistake, and reported the error to management himself, For KOMO to air this story without looking a little deeper is irresponsible. By the way, the reason the pill description is printed on the label for the patient's benefit. They should verify that the description matches the pill. The patient is the final check. If you are not sure, call your pharmacist.
To Koawoodplayer: What should that pharmacist done other than apologize ?
@rx30You bring up many valid and excellent points in your response, but to accuse KOMO of anything seems a bit silly. After all, this is really about a woman who is calling for all sorts of unnecessary safety requirements because of an isolated mistake. That's the story.
Healthcare isn't a one-way proposition. It is up to the provider and the patient both to be aware of the care being provided. As long as humans are involved, errors will happen. While we will never eliminate them, we all need to take reasonable steps to try to do so.
My experience with Rite Aid was giving my insurance card to another customer. It had some sensitive info on it. Was I mad? You bet I was. And all the pharmacist's aid could say was, "I'm sorry." Sorry doesn't cut it buddy, when someone has my information!!
Now, I know they screw up on giving out meds too. Nice to know. Besides, their prices are pretty high, so no, I haven't shopped at a Rite Aid since that first screw up of theirs.
@Koawoodplayer I swear that Rite Aid and the other soulless corporate drug stores, try to get by with as few staff as possible. I was picking up meds for my mom for a while, and finally told her that she needs to switch her prescriptions away from Rite Aid.  Every single time they say the meds are in, you go there.. (and for many elderly or sick customers, that is a major trip,) and they say "oh, sorry, you only have one prescription here.)  After you've called and asked if all were ready, suddenly they aren't. Then suddenly they can't seem to find the fax from the insurance company, then they forget something else.  I assume that the corporate stores like that pay badly, and don't hire enough people.  I would never get a prescription there.Â
@Koawoodplayer I stopped shopping at Rite-Aid because the staff in the pharmacy (been to several locations throughout the Puget Sound) have been rude or just ignore you like you aren't even there. No thanks. There are plenty of other pharmacies around that are happy to take my business and do so without the snark.Â
Maybe they should rename themselves to Wrong-Aid.
Hurhurhur
I think everyone has had a wrong prescription filled before. I don't get why this is news, but I guess we have to tell people common sense things in the news these days, like "Don't light a gas grill indoors or you might kill yourself!". Next the state legislature will get right to work on passing a law about this....you know, to protect the people too stupid to help themselves. Read your prescription label before you pop that pill in your mouth....not hard to do.
@dg54321 I'm glad KOMO printed this story. It enlightens us about the errors made with our healthcare. It can happen, but doesn't often. Who would think to double check a pill that so closely resembles one you have taken before? What if you are a person who is sight impaired or so elderly, it's difficult to even comprehend that you should double check what a professional should be doing in the first place? And as the other poster commented, what if this was your first time on a certain med? You would have no earthly idea what it should look like--even if you were to find a pic of it on Google.
@KoawoodplayerÂ
@dg54321
Maybe it is my first time on a med and I donât know what it looks like, yet all pharms have been including fact sheets with the scripts for years. There is NO earthly reason for a consumer NOT to read and heed. The onus is on the pill-taker, not giver.
@DT Sorry, Iâm a product of the public school system, just not of this era or stateâ¦.
@dome200q Okay, I'm just shocked that a commenter here actually knows, and can spell, the word: Onus.  Â
So she goes to the news? Â Good gracious. Â Mistakes happen. Â Healthcare providers are human. Â This is not the first mis-fill and it won't be the last. Â Â
Maybe if customers would stop asking the Pharmacist: "Where is the bread?" Â "Do you have a bathroom I can use?" Â etc the pharmacy staff would have less interruptions and could focus on what their job is..... FILLING PRESCRIPTIONS not being the store directory! Â (Not saying this is what happened in this case, but this happens way too often.)
@JCCBlvu if you don't your job...quit
@BuddyHollyYou failed to see the point. Why am I not surprised?