My wife got the wrong meds at the pharmacy today

…and everything’s OK. But, herein lies a cautionary tale for all of us.

The pharmacy called her about 20 minutes after she picked up her prescription, and said “we think we may have overcharged you” which was, frankly, an untruth. This was followed by a request to check out the meds in the bag.

The stapled prescriptions on the outside were correct, but the meds inside weren’t the ones on the outside. In fact, the bottle had the wrong name and the wrong medications. This was reported, and “we’d be glad to exchange them” was the basic reply. (I will NOT entertain queries about what was supposed to be prescribed, or what was in the bag. That would, actually, be a good way to get yourself banned from my site for life).

So, she took the wrong meds back, got a bottle of the right meds, compliments of the house, and all’s well that ends well.

This did engender a bit of ‘lawsuit lottery’ fever in the house, with questions about ‘what if you’d taken it’, etc., bandied about. Unsurprisingly, I was having none of it, pointing out that mistakes happen everywhere, and ultimately it’s up to the patient to make sure they’re taking the right medication.

Moral? Look in the bag before you leave, and realize that mistakes happen everywhere. Caveat emptor, and all that.


  1. Dentist, familiar with my med. history, inc orrectly prescribed antibiotic to which I am allergic. The drug store, familiar with my allergeries, filled it anyway.

    After I picked it up, went home and tipped out the two capsules I was supposed to take, I realized they didn’t look right.

    The last time I took this stuff I went to the ER in shock. Couldn’t breathe etc.

    Thing is, neither the Dentist nor the pharmacist every said, oops, sorry.

    Their indifference pissed me off.

  2. This happens so much more often than people think. I know its happened at least twice to my wife in the last couple of years at different pharmacies. My theory is the increasing use of pharmacy techs to fill gaps in service. The 1 week training is no substitute for a couple of years in pharmacy school. Ok, now I’m riled up. Thanks for getting me so fired up at 6:44am. ;)

  3. but would a layman know that the pills inside weren’t the ones lised on the bottle? Did I miss something here?

  4. I would contact the home office of the vendor and relate your story to its risk manager. He may tend to be defensive, but when he hears from another health care provider about his perception of the PR implications of the company’s response to a potential incident, he may be willing to listen.

    As M&M conferences tell us, a near-miss incident can be a learning experience.

  5. Jim H. Thats what I was wondering when I read this. If I go to pick up a new prescription how in the world would I know what they are supposed to look like? I guess we could come home and look them all up online and get a description, but that seems a little crazy.

  6. I should clarify.

    The sack had the right name and pill.

    The bottle within had someone elses’ name and pills inside.

    They’re well aware of the risk management implications: that’s no doubt why they refunded my wifes’ money for the original prescription.

  7. Thank you for clarifying. That was what I was misunderstanding. It was the right meds for the right person just in the wrong bag…:)

  8. I picked up a bottle that was supposed to contain 60 pills, and realized after about 13 days that it must have only contained 30 pills. I sent my husband to pick up a refill and he was told “I won’t give your wife any more because she’s been taking too many.” So my doctor’s office had to waste their time calling the prescription in to another pharmacy. I went by to yell at the pharmacist, because of the potential side effects of stopping a beta blocker cold turkey–he KNEW I only had 3 pills left when he refused to refill it. Half an hour later their delivery guy appeared at my door with 30 pills, the pharmacist having apparently verified my story by counting the pills left in his bottle. Oops.

  9. Several commenters have hinted at this, but no one has actually said it…

    A concern is that, when a new pill is prescribed, none of us know what that pill is supposed to look like.

    Every pharmacy now gives us a long description of the medication, dosage instructions, side effects, contraindications, etc. It’s just printed out by the computer. Usually they staple the receipt to it.

    Why don’t they simply add a labelled color photo of the pill to the other information? One look confirms the correctness or inaccuracy of the filling of the prescription. So simple … and relatively cheap, too.

    It’s a no-brainer, waiting for someone with a brain to decide to implement it.

  10. There’s your million-dollar idea!

  11. As a pharmacist, I would like to apologize for the times that mistakes get through our double and triple checks to the patient. There is no excuse because we are dealing with people’s lives, however, the reality is that mistakes can and will happen. We are always looking for new ways to check our work, analyze why mistakes happen, and fix the problem.

    In response to the person who asked about putting a picture of the pill on the info sheet; the pharmacy that I work at has a description of the pills dispensed on the information sheet. One of the biggest problems is keeping our computer system up to date with the generic manufacturer we are carrying at the time. Pills may look different, but they have the same active ingredient. If you would like to identify your pills, there is an identifier (numbers and/or letters) stamped on each dosage unit. Check out “Imprint Code Identification” to verify your medication.

    When a new prescription is dispensed, I do my best to speak with each patient and review what the new medication is, its use, and open the bottle to show the patient what it looks like. This is a triple check on the work already done. If information I am relaying is different from what the doctor told the patient, we can fix things before he or she leaves the pharmacy.

    Some helpful tips when going to the pharmacy:
    1. As was already mentioned: Be familiar with your medications. Know what they look like and what they are for.

    2. Check your refills before you leave the store.

    3. When getting a new prescription from the doctor, ask what is the name of the drug, dose, directions for taking it, and why it is being prescribed.

    4. Please be patient with the pharmacist and staff. Some stores are very busy, and we want to make sure everyone gets the best care possible. A pharmacy is not a fast food restaurant where orders are ready in 5 minutes.

    5. If you feel that you need to spend more time talking with the pharmacist, find out what is a good time to call or come in when the store is not so busy. We (well, many of us) are always willing to answer your questions concerning your health and medications.

    6. If you are still not satisfied with your pharmacy, look for a new one that will suit your needs.

    7. If you ever have any doubts, do not be afraid to ask a question.

  12. When u go for buying new medication please check pharmacy because every pharmacy now gives us a long description of the medication, dosage instructions, side effects, contraindications, etc. It’s just printed out by the computer.