I lived half of every pharmacists nightmare tonight. Misfill. An absolute, tee-total, unqualified no excuses prescription filled incorrectly. Yay for me that I wasn't the one who filled it wrong. Woe for me that I was the one working when it was brought to our attention. Written for Lipitor 20mg and filled with 40mg instead. The customer was given 100% more drug than he was meant to take. Here's where it gets interesting though. You know what he did?
In a world where we have to specify that antibiotic liquids have to be taken by mouth and not put in the ear "because that's where the infection is......"
In a world where we have to be sure to tell people that they have to unwrap and remove the foil from a suppository before they stick it up their ass.......you know what this customer did?
To those of you in the profession, what I'm about to write may be the least believable thing you have ever seen on this blog, but I swear it's the truth.
The customer saw the 40mg tabs, realized they were wrong, broke them in half, and took them, 20 mg at a time, mentioning the mistake only when he came in to get his refill "because I know that type of thing is important to you"
If Nobel Prizes went to pharmacy customers, there would be no question as to its first recipient.
15 comments:
Just curious, but is it cheaper that way? I've heard of some insurance companies offering pill splitting programs and such, because the 40mg can be less than twice as expensive as the 20mg. Obviously, that would have to be noted to the patient.
This one incident has restored a little bit of my faith into the survival of the human species. Maybe a FEW will survive after all :-D
Last night we had a misfill of sorts as well... Jane Smith born sometime around the dinosaurs came in for a prescription... when we typed it up, we accidentally filled it using Jayne Smith's profile, born in the 70s somtime. She just called us up and said "just wanted to let you know so you can fix your records!"
Everyone was delightful last night except for our new Medicaid pt. She's only been coming here for a couple weeks, we need to figure out how we're gonna weed her out.
There are good days in the pharmacy. Every once in a while, there are good days.
"Yay for me that I wasn't the one who filled it wrong. Woe for me that I was the one working when it was brought to our attention."
That was always the way it worked when I was in retail. My partner would fuck something up and I'd be the one who got yelled at the next day when the irate customer came back to the pharmacy. Fun times!
By any chance, was the customer you're writing about a former pharmacist? That's the only explanation I can think of for him handling the misfill as well as he did.
Holy Shit, were you high on Ambien dust at the time?
This man had the same idea one of MY patients had a few weeks ago....
"you were out of B-6 last week, so I just bought B-12 and take a half of one..."
When I told her they were two totally different compounds, she swore the "other pharmacist" told her to take it that way. (Funny, the description of that "other pharmacist" didn't resemble anyone who'd ever worked at our store!?) LOL
OMG 2 x Vit B6 = Vit B12... that's brilliant! Actually, that's scary. It would make perfect sense to someone who wouldn't know that B6 = pyridoxine and B12 = cyanocobalamine
What bonehead pharmacist made that suggestion?
DrugNazi, what did you tell that Lipitor patient? I hope your DM is sending him a fat gift card. That one's a keeper!
i had an error come back to me this weekend too. not one i made, thankfully.
right drug. right strength. wrong person's name on the label. now, in the grand scheme of things this is an error i can live with, but wrong person's insurance was billed etc etc.
what i can't figure out is how it happened. why wasn't it caught when we called the person's name? we always double check addresses - why wasn't it caught? why wasn't it caught in our counselling? and why the holy hell did she not notice in the time since the original fill (NOVEMBER!!!) that someone else's name was on the label??!?
oh wait. she did. she just thought that must be the name of the pharmacist who filled it or something.
*head shake*
When nitroglycerin came in grains (one one-hundredth grain, one one- hundred-fiftieth grain, and also one two-hundredth grain), I had a nurse state that she gave a patient #2 one one-hundredth grains because there were no one two-hundredth grain tablets available, i.e.,
1/100 + 1/100 = 1/200.
I understand that in this case the patient did the right thing, but if the medication in question was let's say, Procardia XL, you wouldn't be so happy the patient had figured things out on their own. Glad it worked out for you, though.
I would have cried if one of our patients said that out of sheer gladness. (Just this week, I caught a patient taking her blood pressure medication twice daily instead of once daily, as stated on both the bottle and on the hard copy. When asked why, she said "I just thought it should be twice a day." *headdesk*
Ur lucky. One of my customers would have taken two of the 40mg just for the hell of it.
I was on a psych ward and the nurse almost gave me the wrong anti-depressant. I was like "This isn't my medication. The pill is the wrong color." I guess the pharmacy sent up the wrong pill and she didn't bother to double check. It wouldn't have killed me -- I think it was Prozac instead of Effexor or something -- but holy hell, the look on her face was priceless. As the patient, I wasn't really bothered. Hell, I probably wouldn't have noticed if I had taken the wrong pill. It wasn't until later that I realized that she could have gotten into some biiig trouble had it gotten around that she gave me the wrong med; even if it was a med mix-up that wouldn't have harmed me.
this guy must have some inside knowledge somehow. He knew that he could take half, and he knew that he was getting two months worth of med for 1 month copay and that if he would have complained right away, you would have taken it back and given him a one month supply in exchange. Smart dude!
That's what I was thinking. He got 2 copays for 1. The person who got the wrong patient name/billed to the wrong ins probably didn't speak up as the wrongly billed patient's insurance had a lower copay
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