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FYI - Pharmacy Meds - Important

Moms View Message Board: General Discussion: Archive October 2006: FYI - Pharmacy Meds - Important
By Amecmom on Thursday, October 5, 2006 - 07:45 pm:

I thought I would pass this along. PLEASE check any medication you get from the pharmacy that does not come in it's original packaging, especially liquid medication, and question anything that seems different. Here's why:

My daughter (2yrs) is on Zantac for GERD. I just (3 days ago) refilled her prescription and noticed that it smelled different. I assumed that they'd changed the formulation to make it more palatable to children.

Tonight after discussion on another topic about Zyrtec, I told Helen she was getting Zyrtec when she asked me what the medicine was (she always does this), then I realized my mistake and said, no, it's Zantac. Then a light bulb went on in my head. I knew the smell of the medication was familiar ...

I called the pharmacy and found out that the formulation for Zantac had not been changed! Zantac has a very unmistakable odor. They had filled the script incorrectly with Zyrtec!

Now my questions as to why her reflux suddenly got worse and why she's been off the wall the past few days are answered!

The scary thing is I just gave her Benadryl with what I thought was Zantac. Now she has a mega does of antihistimine in her.

The pharmacist was very apologetic and assured me that there should be no problems with the Zyrtec and the Benadryl interacting.

I'm still shaking. What if they had mixed up the Zantac with something like Orapred (which is also clear and tastes berry-like)? Actually, it could easily be that. I'm just assuming what they put in the bottle is Zyrtec because it smells and tastes like it.

So, please, please double check everything!!!


By Luvn29 on Thursday, October 5, 2006 - 08:10 pm:

Oh wow! I am very familiar with the Zantac and yes, it has a VERY distinct smell! Good for you for knowing the smells of her medications. Unfortunately, many parents would have never noticed the difference.

That's very scary.

My son was on liquid Zantac for a very long time. Now he is on Prevacid, the kind that dissolve. I had his prescription refilled after months of the same med, and gave him his pill, and HE told me that it was the wrong medication. I thought it looked different, but didn't pay much attention, so I checked it out, and it was a different mg than he usually takes! His stomach is VERY touchy, and we have just gotten to the point that he is doing very well. This could have really messed things up!

Thanks for the reminder and glad you noticed so quickly!

By Amecmom on Thursday, October 5, 2006 - 08:33 pm:

My son is also on the Prevacid. Her reflux had gotten so bad over the past few days (hiccups, coughing, not eating, etc) I thought they were going to have to put her on it, too. Kudos to your son for noticing the error!

I would never have thought twice about the smell of the Zantac if Zyrtec had not been in my head. If I could slip up on the names so easily, couldn't the pharmacist have done the same? Thanks to Momsview, I had Zyrtec on the brain.

By Nicki on Thursday, October 5, 2006 - 10:51 pm:

Ame, thank you so much for sharing this with us! I never think to double check Lara's prescriptions. I will now.

I hope Helen will be okay. Hugs to you, too. I can just imagine how upsetting this would be to you.

By Tink on Thursday, October 5, 2006 - 10:57 pm:

I don't know if this is common practice among pharmacies now but our's puts a small label describing the color, size (if it's a tablet) and any smells or flavors of the medication prescribed, just for this reason. I've yet to catch an error but I do double-check my meds versus the description each time. It might be worth talking to your pharmacist about something like this. {{{Ame}}} I'm glad you caught this and that it wasn't anything more serious. Personally, I'd want some kind of reassurance that this couldn't happen again to me, my children or anyone else.

By Cocoabutter on Thursday, October 5, 2006 - 11:04 pm:

He works in mysterious ways....

By Karen~admin on Friday, October 6, 2006 - 07:38 am:

I check ours each month. Our CVS puts a sticker on the label if they get a generic form of a med that is different in appearance from what you are used to seeing.

By Amecmom on Friday, October 6, 2006 - 09:56 am:

That's a good idea, Tink. The fact that they need a system like that tells me how common mistakes are. But, I keep thinking: what if this was a medication I had no experience with? What if this was a new baby with reflux who was given an antihistimine (which are not used in children under 6 months)instead of Zantac? If I had no experience with both Zantac and Zyrtec, I would NEVER have known something was wrong.
It could have been dangerous. My husband says I should report the pharmacy to whoever oversees this kind of thing, but I know people make mistakes and I don't want someone to lose their job over something that turned out just fine.
I'm thinking that I want the pharmacist to have a meeting with his staff to discuss this and highlight the need for added care when filling scripts that don't come in original packaging. Maybe I'll bring up what your pharmacy does.
Thank goodness she's fine. She just had a great night's sleep. Not me, though. I was listening for every breath on the baby monitor.
Thanks for your support.
I think whenever I get a new med, I'm going to ask to see and smell the original bottle and then check mine to be sure it's the same.
I'll just be the PITB customer ...

By Tarable on Friday, October 6, 2006 - 10:12 am:

A few months ago my DH came home after picking up his blood pressure meds and noticed they were different looking so he looked up the pill that he got on the internet and it was cholesterol medicine. Always remember if it is a pill you can look up the little code on the pill and it will tell you what the pill actually is.

I can't imagine if they gave me the wrong liquid med since we don't have those around normally.

By Ginny~moderator on Friday, October 6, 2006 - 06:06 pm:

Ame, I have mixed feelings about your last post. I understand that "everything turned out alright" and you don't want someone to lose their job. But, on the other hand, should someone who made a mistake like that keep a job that has them handing out medicines and maybe handing out the wrong ones. If it were me I would definitely make a written, formal complaint to the pharmacy, and as them to respond in writing as to how they are going to deal with this. If it's not in writing, it doesn't leave a record or trail.

By Kate on Friday, October 6, 2006 - 06:54 pm:

I checked with my pharmacy friend. She says in her store (which is New York state) when that happens it gets written up in the pharmacist's file. Obviously if it happens again and again action is taken, but for just a few offences it just gets written up in the file. It does happen, it's scary and can be fatal. That's why they make so much money! I would go ahead and write the formal complaint, but I don't know who you would send it to exactly. You have to trust that this was noted in the pharmacist's file, but I'm not sure that would make me feel much better. She says in her store the pharmacy techs (NOT actual pharmacists, but just people who have been trained at the store) fill the prescription, then send the filled prescription, along with the doc's orders and the big bottle it came from, down a line to the real pharmacist. She then checks the doc's orders against the drug, and checks that the drug is the right one. She does this easily since the bottle it came out of is also right there. If all is well, the big bottle goes back on the shelf. If someone needs to fill from the big bottle for another prescription and it hasn't been checked yet by her, she will make them wait, or stop and go out of order and check that particular one so that the tech may then use the big bottle for someone else. By big bottle I merely mean the large bottle of pills or vat of liquid they are dispensing from into the small bottles given to the customer. Each bottle or pill has a code on it that must match the drug. If she receives a liquid on the line that is NOT accompanied by its big bottle, she throws it out and has the tech do it again. If it's pills she can check the code number on the pill to see if it's the right drug.

She wondered if the pharmacist misread the doc's handwriting since the two drugs are so similar in name? She also said some companies have their drugs in identical bottles which makes it easier to mess up.

I'm sorry it happened to very scary. DEFINITELY be the pain in the neck customer! You should ALWAYS be a pain when it comes to your health or safety.

By Tripletmom on Friday, October 6, 2006 - 06:55 pm:

Ame-I would definatley report it to the college of pharmacists.I work in a pharmacy and its sad how this happens.Both those meds start with a letter A and end with a letter C and both have 6 letters each.It could have been more fatal.Here in Canada we are seeing more electronic prescriptions so these errors don't happen.Some doctors prescriptions handwriting is so awful that these mistakes happen.The last desicion is up to the pharmacist and they should have held onto the rx until they verified it with your doctor.I believe in the States a few years ago there was a problem with losec(stomach pill) and lasix(water pill,B/P)too many errors with drugs looking too much alike on a rx.I think they changed losec to another name but I'm not sure.In Canada we still call it losec.They're too many drugs these days that sound and look to much alike.

By Amecmom on Friday, October 6, 2006 - 08:50 pm:

No, this was not an error reading the script. This was a refill - so it was already in the computer system. The label on the bottle said Zantac - so they read the right med. The pharmacist or tech just poured the wrong liquid in the bottle. I was told that a Zantac/Zyrtec mix-up is the most common pharmacy error.

I will speak to the manager and go from there. I am also going to alert my dr's office to tell now moms or dads that when they get Zantac for their babies it should smell like mouthwash - if it smells sweet, it's the wrong med.

Ginny, I understand. My husband is a litigator who had handled cases where the results of the wrong med being dispensed were disasterous. Maybe that's why I am reluctant to file a formal complaing, because this was so minor. But, then again, it could have been very bad. I don't really know what to do....


By Ginny~moderator on Saturday, October 7, 2006 - 07:07 am:

Ame, I am not thinking of it from a litigation perspective. I am thinking of it in terms of having something permanent in this pharmacy's and this technician's/pharmacist's records that this error was made. If the system works in your pharmacy like the one Kate describes, two people made errors - the technician who actually filled the bottle and the pharmacist who was supposed to double-check.

Yes, it was minor, because you caught it. You're an educated, fairly sophisticated person. But, what if your daughter had been given Zyrtec instead of Zantac for a week, or until the bottle was empty? Someone who is not as well educated or sophisticated might have done that.

Again, I urge you to make a written, formal complaint so that it goes into the official records. Otherwise it may just get swept under the rug, with a private word from the pharmacy manager to the technician and pharmacist involved but no record. If there's no record, neither of them has any job-keeping motivation to be more careful. Yes, I know all pharmacy employees try really hard to be careful - they know they have people's lives in their hands. But honestly, this shouldn't have happened, and one way to make sure the people involved are much more careful in the future is to have it on the record.

This kind of double-checking has gotten even more important with the prevalence of generic drugs. The generics are not the same size, shape or color as the "brand name" drugs, and there may be more than one generic for a drug. As a result, pharmacy employees are more likely to quickly assure a consumer that "its different because it's a generic", and consumers are less able to be sure if they are getting the right medication unless they do as someone above did, and check on the internet.

I don't understand why all pharmaceutical companies and pharmacies are not using bar coding and bar code readers. I am reminded of the error that took place in a hospital recently, where premature babies were given the wrong dosage of heparin because a pharmacy technician restocked the pediatric ICU with the wrong bottle. (Heparin, in a very mild dose, is used with very premature babies to keep clots from forming around the IV and other tubes being used.) The technician put the wrong dosage bottle in the cabinet, the nurses took it out and used it (also not reading the label), and at least three babies died. Bar codes on the bottles and a bar code reader next to the medicine cabinet could have prevented that. From what I've read, the 8th leading cause of death in the U.S. is medical errors, which includes medication errors.

By Tripletmom on Saturday, October 7, 2006 - 09:42 am:

Wow,a big mistake like this on a refill.I'd definatley call the pharmacy manager and put a complaint in.It should not have left the pharmacy.Even though it turned out for the best it still needs to be reported.They need to implement a system so this doesn't happen again.

Ginny-We go to the barcode system in November at the pharmacy I work for.I think it will cut down on errors.

By Coopaveryben on Saturday, October 7, 2006 - 10:26 am:

I had this happen this week. My DS is on 60mg of Stratera and I picked it up, gave it to him for several days (about 5) and then happened to look down at the pill and it was 25mg! This was in a sealed bottle but their label covered the outside of the bottle and I just didn't look close enough at the pill and in the morning I didn't notice the color difference. They fixed their mistake but when my DS went back on the 60mg his body had to readjust (because we had slowly and carefully built up to the 60mg) and he had an upset stomach and was sleepy until his body got used to it again.

I feel bad that he didn't feel well because of it but it did make me think of the dangers if it had been a more serious medication! It is good you knew what Zyrtec smelled like.

By Cocoabutter on Saturday, October 7, 2006 - 01:37 pm:

I have only skimmed thru the responses, so if this was mentioned, I am sorry if I repeat it.

Yes, the mistakes were caught before anything serious happened, so one might say- "No harm, no foul."

However, if there is a pharmacist or a pharmacy technician who is not being careful when filling prescriptions, it could infact be a matter of life or death for someone else.

Insisting that action be taken now could save someone else's life later.

By Ginny~moderator on Sunday, October 8, 2006 - 07:10 pm:

Ame, I've been thinking about this, and still think that you should make a written report. You don't know if this was the first mistake this pharmacy tech and/or pharmacist made, or if there were other, similar errors in the past. I think it is really important to document this kind of error.

By Tripletmom on Sunday, October 8, 2006 - 07:35 pm:

Ditto Ginny

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