Pharmacy Dispensed Wrong Item

Anetares

I had a mistake recently but it worked sort of in reverse.. I was getting mine for christmas (morphine, tramadol, fentanyl, and warfarin strong stuff), collected the repeat in a hurry, as usual, went down to Boots. I handed it over and they asked if it was right... I'd been given a prescription for co-codamol, simivistatin (cholesterol) and Diltiazem (heart medication) ... I'm highly allergic to codeine, constricts my breathing, and I have warfarin which acts on the blood, so an interaction with things for heart problems or cholesterol could be quite nasty. In my case it was the pharmacy who saved the potentially fatal mix up. Prescription had my name on it but no address etc., turns out the GPs gave my morphine and warfarin to someone with heart and cholesterol problems...

I complained, it's going through heartlands PCT and every trip to the doctors now is hell, I'm treated like I'm going to give them SARS or something... No £25 vouchers here.

krisskross

mum2one wrote: »

Worst thing is the prescription was for pencillian which I am allergic to - very severe consequences - all over my medical records no pencillian-

I am absolutely seathing, this could of been very serious, I only didnt take it as I thought Im sure I was meant to have ear drops.

I find it totally amazing that anyone would consider taking any drug that they were unfamiliar with without carefully checking the actual drug, the dosage and any other instructions.

I realise you are looking for someone to hang out to dry on this, and there is certainly a need for additional staff training but we all have to take responsibility for what we swallow. Nothing detrimental happened, no one was damaged. I am sure lessons have been learned and procedures will have been implemented to make sure it doesn't happen again.

Anetares

Not everyone has the luxury of being with it enough to check exactly what they're taking.

I, myself, have fentanyl patches and oral morphine (multiple spine fractures), when I was at the height of taking them (20mg fentanyl/60ml morphine), if I was given anything additional I would have just picked it up and swallowed it. Considering my various allergies, it could have been lethal, so I did rely on my doctors and pharmacy giving out the correct things.

Every case has different circumstances.

Plus, in the case that this person has experienced, what if it had been an older person, maybe bordering on Alzheimer's, they would most likely just take their pills.

krisskross

Anetares wrote: »

Not everyone has the luxury of being with it enough to check exactly what they're taking.

I, myself, have fentanyl patches and oral morphine (multiple spine fractures), when I was at the height of taking them (20mg fentanyl/60ml morphine), if I was given anything additional I would have just picked it up and swallowed it. Considering my various allergies, it could have been lethal, so I did rely on my doctors and pharmacy giving out the correct things.

Every case has different circumstances.

Plus, in the case that this person has experienced, what if it had been an older person, maybe bordering on Alzheimer's, they would most likely just take their pills.

I was a nurse in palliative care and would have been horrified if prescribed drug dosages had been so poorly titrated to pain levels that a patient would take stuff willy nilly without questioning or reading the instructions or yet checking that it was actually intended for them.

People with Alzheimers would have carers dealing with their medication or it could be dispensed in dosett boxes. Sorry but sometimes folks get carried away with imaginary scenarios when nothing detrimental has actually happened. The person I feel sorry for is the poor chap who didn't get his antibiotics.

Anetares

Well, I said bordering on, implication being not having a diagnosis, I know plenty of older people, friends of my older relatives, who have to do their own pills for the week, fill those weekly boxes themselves. There is inconsistency between brand name and generic label drugs dispensed, so its easy for them to get confused.

And as for my own situation, its not unlike receiving 4-5 hourly IM injections of morphine in hospital, the nurse gives you a bundle of other pills and you just take them... through trust. It's the same for a lot of other people, even if you don't automatically recognise the carton something is dispensed in, you tend to think you should take it anyway because you're not a healthcare professional, so you trust that you should take what you're given because you're lead to believe it is in your own best interests.

I always read the patient information leaflets and look things up online, but few people do. Ok, that isn't 100% responsible of them, but the dispensers and prescribers also have a duty of care to the patient, the same as any organisation providing a service.

Mistakes like this persons need to be called to account because of that one time in a million when it may affect someones health. There isn't such a thing as being too cautious when health and lives are involved.

There's also another factor involved though, over the Christmas period, if somebody gave your medications out to another person a few days before Christmas, it could leave you without some very necessary things, for instance if the person was diabetic or asthmatic... that in itself can cause problems.

And I forgot to add, so *edit*... In this case though, I don't think it's entirely fair to go the PCT route if it was a mistake of the shop.. the shop should be the ones held to account if they're the ones who made the mistake of handing out the wrong persons medication. Exactly what are the rules governing a pharmacy concession?

krisskross

I do hope none of you ever go to live in Spain. When a prescription is filled there there are no typed instructions, no patient name etc. Just packets of pills straight off the shelf and all the details in Spanish obviously. You learn to listen very carefully or take an interpreter with you to the doctor so you know dosages etc. The Spanish treat you like adults and assume you check before you swallow.

krisskross

Anetares wrote: »

And as for my own situation, its not unlike receiving 4-5 hourly IM injections of morphine in hospital, the nurse gives you a bundle of other pills and you just take them... through trust.

I have to say I found nothing more infuriating than to dispense a patient's drugs into the little cup thingy, check the patient identity against the drug chart. The patient would look at the tablets in the cup, swallow them and THEN tell me they thought I had made a mistake.

sillyvixen

my mum got home from shopping to find a item through the letter box in a tescos bag. closer inspection revealed it to be a pharmacy delivered box of diazapam it had been delivered to her house instead of the same number several streets away. i hate to think what may have happened if had been delivered to a house with children and they had got their hands on it!! anyway she returned it to tescos pharmacy explaining the error their driver had made, only to be asked why she hadn't just taken it to the correct house and they tried to lay the blame on her if the correct patient didn't get the pills on time!!:mad:

krisskross

sillyvixen wrote: »

my mum got home from shopping to find a item through the letter box in a tescos bag. closer inspection revealed it to be a pharmacy delivered box of diazapam it had been delivered to her house instead of the same number several streets away. i hate to think what may have happened if had been delivered to a house with children and they had got their hands on it!! anyway she returned it to tescos pharmacy explaining the error their driver had made, only to be asked why she hadn't just taken it to the correct house and they tried to lay the blame on her if the correct patient didn't get the pills on time!!:mad:

Oh dear now that really is a dreadful mistake to make. I was under the impression that prescription only medication which diazepam certainly is could not be given to the patient unless the pharmacist was present.

sillyvixen

krisskross wrote: »

Oh dear now that really is a dreadful mistake to make. I was under the impression that prescription only medication which diazepam certainly is could not be given to the patient unless the pharmacist was present.

well this was not it was put through the wrong letter box by the pharmacy delivary service!!! beggers belief really.