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18 Pharmacists Discuss Their Most Memorable Medication Mistakes

Have you ever gotten the wrong drug from the pharmacy? Here, pharmacists reveal their memorable medication mistakes.
18 Pharmacists Discuss Their Most Memorable Medication Mista...
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This is another excerpt from pharmacist Dennis Miller’s new book The Shocking Truth About Pharmacy: A Pharmacist Reveals All The Disturbing Secrets. The Kindle e-book is available for download on Amazon for 99 cents. In this excerpt, pharmacists reveal their own memorable medication mistakes.

Memorable Medication Mistakes:

I received a lot of interesting feedback from pharmacists in response to my articles in Drug Topics (a popular magazine for pharmacists) on pharmacy mistakes. One of my articles described a potentially serious error I made myself involving the sleeping pill Halcion.

One pharmacist wrote to me,

“Getting a pharmacist to admit an error is like trying to get a woman who has had an abortion to talk about it. It is not going to happen.”

Apparently many pharmacists disagree, seeing significant educational value in discussing their errors.

For example, another pharmacist wrote,

“Thanks for sharing your experience. I think hearing about other pharmacists’ mistakes is a great way to hopefully prevent them from happening again.” 

A Sampling of Pharmacy Errors:

Several pharmacists e-mailed me with their own most memorable misfills. Some of these memorable medication mistakes are far more serious than others. Here’s a sample:

[1] Pharmacist dispensed chili peppers instead of diabetes medication

When I had my pharmacy in West Los Angeles during the 80’s, filling 300 to 500 prescriptions per day, I had, as an employee pharmacist, one of the fastest and most accurate Rx fillers. I’ll call him JT. He could clear the counter in a nanosecond.

There was a hot dog stand connected to the outside of my building and JT had the habit of taking a 20 dram vial and filling it with chili peppers so he could snack on them while filling prescriptions.

Anyway, JT worked every other day for me so one day, after he had worked, I received an absolutely frantic call from one of my best and oldest customers. She was sobbing, knowing that the story she was about to tell me would be hard to believe.

She had picked up her prescription the day before. But when she went to take her prescribed medication that morning, she opened her 20 dram vial to find, not her diabetes medication, but eleven chili peppers. “How could this be?” she asked, her voice trembling, for she had paid a hefty price for her medication.

At first, I could not believe her and was a bit dismissive. But all of a sudden, in the back of my mind, I remembered JT’s habit of filling a vial with chili peppers.

What could I say but to convince her that someone had broken into her house in the middle of the night, stole her diabetes medication and replaced it with chili peppers?

It took almost an hour and one-half on the phone with her and in the meantime, her prescription was filled correctly and sent out. I was still on the phone with her when my delivery person arrived, and she was so thankful.

I was her hero that day and I am ashamed.

[2] Pharmacist failed to catch technician’s error resulting in ear drops being placed in infant’s eye, sending child to emergency room

One day I was working late (12 hr day) for CVS. It was just before closing time. A customer came in with an Rx for an eye drop for her infant baby.

The tech typed the Rx for an ear drop with the same name [Cortisporin ear drops vs. Cortisporin eye drops]. I was tired and wanted to go home, so I filled it not realizing it was incorrect.

I found out later from my supervisor that it was used in the eye. Baby went to ER and luckily no permanent harm to the patient, but plenty of harm to me.

Of course, you only learn from your mistakes, and any eye drop Rx I fill is double checked.

I find it very interesting when I am working a long day (checking 300 Rxs), I might find 3 or more mistakes either at drop off or at filling. I correct them and all is well.

Then I go home and I say to my wife, I corrected some Rx errors today, I wonder if I missed any.

Here is a very similar case in which a man claims he was blinded in his left eye after a CVS pharmacist mistakenly dispensed Cortisporin EAR drops instead of Cortisporin EYE drops.

Man claims CVS mistake cost him his sight
Kevin Reece
KHOU-TV, Houston
January 20, 2014

HOUSTON — A man has sued CVS Pharmacy claiming he was blinded in his left eye after a pharmacist mistakenly gave him anti-bacterial ear drops to treat an eye infection.

Claudis Alston, 65, suffers from a variety of ailments including kidney failure. But in 2012, he sought treatment at Houston Methodist Hospital for an eye condition and was diagnosed with pink eye/conjunctivitis. Medical records show he was given a prescription for a common conjunctivitis treatment – Cortisporin Ophthalmic Suspension. He got that prescription filled at a local CVS Pharmacy.

In the lawsuit filed this week, Alston’s attorney displayed the original packaging and instructions that came with the solution CVS gave him. Instead of Cortisporin Opthalmic Suspension, the packing says it contains neomycin-polymyxin-HC. It is a treatment for bacterial ear infections. The packaging identifies it as an “EAR SOLN.” But the instructions say, “INSTILL 3 DROPS IN EACH EYE TWICE DAILY FOR 5 DAYS.”

[3] Pharmacist handed nurse regular heparin (an anticoagulant) instead of heparin flush (used to flush intravenous catheters), requiring heroic reversal of the life-threatening thin blood it caused one patient

“I was in my first or second year out of school, working in a 250-bed hospital. A nurse came to the pharmacy, wanting floor stock heparin flush.

“I went to the heparin shelf, not knowing what I was doing, and selected a box of 5000 unit heparin, not flush. At the time, I didn’t even know that there was a difference in heparin to flush a line and heparin to anticoagulate. I handed it to the nurse without a thought.

“It turned out the nurses flushed with the full strength heparin that I dispensed and they had to do heroic reversal of the life-threatening thin blood it caused one patient.

“At every pharmacy where I have worked since then, I have separated the heparin flush from the regular heparin and put a big sign by the regular heparin that said, ‘NOT FOR FLUSH.’”

In a commentary titled “Vial Mistakes Involving Heparin,” Tim Vanderveen, Pharm.D., writes about some memorable medication mistakes:

At Methodist Hospital (Indianapolis) in 2006, three infants died and three were injured when nurses administered heparin flushes prepared from 10,000 units/mL vials rather than from similar-looking vials containing the 10 units/mL concentration used to flush intravenous catheters.

The 10,000 units/mL vials had inadvertently been loaded into the automated dispensing cabinet (ADC) drawer that usually held 10 units/mL vials, and multiple nurses administered the high-concentration heparin as catheter flushes. One year later at Cedars-Sinai Hospital, Dennis Quaid’s newborn twins also were administered high-concentration heparin in place of the heparin flush.  

Source: PSNet (Patient Safety Network), Agency for Healthcare Research and Quality, an official website of the Dept. Of Health & Human Services, May 2009

[4] Pharmacist dispensed 600 mg of anti-seizure drug gabapentin instead of 100 mg, sending woman to hospital

Yesterday my DM [district manager] called to tell me I had dispensed a Rx for 100 mg gabapentin as 600 mg. [Gabapentin, the generic for Neurontin, is an antiseizure drug that is also used to treat various neuropathies / neuralgias. It is available in strengths from 100 mg to 800 mg.]

I researched it and found that the tech had input [entered into the pharmacy computer] 600 mg and I, on checking, let it get by me. The lady took it for 2 weeks and is in the hospital being weaned off it.

I feel like crap!! This is the scenario: It was in hour 10 of a 13 hour day. I had not eaten a thing all day. We had a stack of 35 baskets to input and did 398 Rx’s that day. One pharmacist [on duty] all day.

At the time of the error [there were only] one input tech and one cashier [on duty]. Put that in your book next to a picture of a pharmacist throwing up. That’s my picture.

[5] Pharmacist failed to question excessive pain medication, sending patient to emergency room 

“In 2008 I filled a Rx for morphine extended release 200 mg TID [three times a day]. The Rx was from a pain specialist who had been treating our mutual patient, an elderly female, with hydrocodone/acetaminophen 10/325 TID plus an Rx for [the muscle relaxer] carisoprodol.

“Knowing the patient and the doctor, I filled it. It was in his handwriting. Thinking she had taken a turn for the worse, I did not question it.

“She took one dose and ended up in the emergency room. After she was released from the emergency room, she immediately contacted a lawyer and tried to sue my pharmacy and the MD.

“I ended up paying for her ambulance ride to the ER and a fine from the board of pharmacy. The pain specialist who wrote the Rx suffered no repercussions.

“At the time I was afraid to question the all-powerful pain specialist. How dare I question his prescriptions!

“Should I have been disciplined? Now I would say yes. Should the MD who wrote it have been cited? I think if I was in error, he was complicit in that error.”

[6] Pharmacist gave 350 units of insulin instead of 70 units, sending patient to intensive care

“I made a mistake which will forever haunt me. U-500 insulin, gave 350 units rather than the desired 70 units. Sent the patient to the ICU overnight (recovered fine).

“Inexplicable! I knew the insulin, knew the risks, I completely knew better, and still made this damned mistake! Still makes me feel so stupid every time I touch ANY insulin. Probably a good reminder, but it still hurts, years later.”

[7] Pharmacist dispensed two drugs that interact: anti-histamine Seldane and heart drug quinidine

“My biggest error was dispensing terfenadine (Seldane) to a patient on quinidine. I contacted the cardiologist but he said that’s what he wanted, so I dispensed it. The patient ended up dying of sudden cardiac arrest a few months later.”

Terfenadine is no longer on the market because of its propensity for causing serious drug interactions. According to the drug interaction checker on drugs.com, there is a MAJOR interaction between terfenadine and quinidine:

Using quinidine together with terfenadine can increase the risk of an irregular heart rhythm that may be serious and potentially life-threatening, although it is a relatively rare side effect. You may be more susceptible if you have a heart condition called congenital long QT syndrome, other cardiac diseases, conduction abnormalities, or electrolyte disturbances…

[8] Pharmacist dispensed wrong type of alcohol, causing permanent scar on face of young female

About 1957 when I was a young owner, I employed a much older pharmacist. He supplied isopropyl alcohol on a open call for rubbing alcohol. (Alcohol USP means ethyl alcohol.) The young lady squeezed a zit, dabbed on alcohol, took a nap, and woke up with a burn on the temple area the size of a quarter.

My insurance adjuster said juries are very sympathetic to young ladies with scars but he would settle in such a manner that we would keep the customer. Six hundred dollars for plastic surgery did just that and the family remained patients for 42 more years.

When I saw the girl, now a grandmother, in the Shop-Rite last year, the scar was still there.

[9] Pharmacist did not catch technician’s mistake and dispensed blood pressure/angina drug nadolol instead of anti-psychotic drug Haldol 

“My worst mistake as a pharmacist was a handwritten prescription for Haldol, which my technician mistakenly typed for nadolol. I did not catch the mistake, and the patient took the medication for a few days before returning to the pharmacy. We corrected the prescription and let the patient’s doctor know.

“The patient was fine, but it could have been disastrous! I agree with you that I punished myself hard for this one and have had self-doubt since, especially on handwritten prescriptions.”  

[10] Pharmacist dispensed amphetamine diet pill with directions “four times a day” instead of “once a day”

My most memorable error was on the typed sig [directions] on a Dexamyl Spansules prescription, a popular diet pill by SK&F (Dextroamphetamine/Amobarbital). Of course, the sig was one a day. I typed four times a day.

Gadzooks. The poor woman didn’t eat a thing for 2 days. She did not sleep either. When she came in, I confessed and made the correction. This was around 1968. She continued to trade with us. Acted as if nothing had happened.

[11] Pharmacist dispensed 100 mg of the steroid SoluMedrol to infant, instead of 10 mg

“I have made a few memorable medication mistakes. I think the worst was overdose of SoluMedrol to infant (should have been 10 mg, dispensed 100 mg). No harm but to my psyche. None of us are immune to mistakes. It’s not making one, it’s how we handle the ones we make.”

[12] Pharmacist dispensed 25 mg of antidepressant Pamelor instead of 10 mg

Back in 1988 in Puerto Rico a lady came to the pharmacy to get her Pamelor refilled for the third time. She left and then came back to tell me that I had given her the wrong medicine. I looked at it and I had indeed filled it correctly (Pamelor 10mg). She said “But the one you gave me last month was such and such color.”

We had given her 25 mg Pamelor the previous month! I explained the filling error to her. She then looked at me and said “Look, I have not felt this good for a long time. You have got to misfill it again!” I explained to her that I could not do that. Later that week we got a call from her doctor for a new prescription for Pamelor 25 mg!

[13] Pharmacist mistakenly dispensed the tension headache drug Fiorcet with Codeine instead of plain Fioricet

“I have been working chain pharmacy since I graduated. It only took me two years to have my initials land in the “Recent Board Discipline” section of the state board newsletter. The entry is fairly anonymous and read something like this: “[Pharmacist’s initials], $500 and 6 additional CE [continuing education hours] fine for failing to…’

“Never at any point have I felt ashamed about it, though sometimes I’d like to have that five hundred bucks back. 

“The situation was this. A regular customer came in to pick up several things and drop off a Fioricet Rx. It was oddly not too busy at that moment, so I had it entered in the computer and reviewed quickly. About nine months later, my Rx supervisor informed me that the board would fine me for the Rx.

“I had incorrectly typed it as Fioricet w/codeine. When the 1+5 total fills had expired and we went to renew it, the physician renewed it as [plain] Fioricet. The patient complained to the physician that Fioricet w/codeine worked much better and demanded that.

“Probably frustrated by my mistake and the patient’s demands, the physician decided the board needed to punish me.”

[14] Pharmacist dispensed 250 mg of antibiotic Amoxil instead of 500 mg

“One of our pharmacists filled a prescription incorrectly with Amoxil 250 mg instead of the written Amoxil 500 mg. The error was discovered on the refill.

“The patient filed a complaint with the state board, which contacted my employer, and two other pharmacists and I had to appear before the board.

“Since there was not any proof on the Amoxil Rx who filled it, being the manager, I went as a representative of the store, the other pharmacists, and the company. The lawyer engaged by the company advised me to just accept whatever disciplinary action was meted out and not to contest it. The lawyer was someone who often appeared before the board in defense of pharmacies and pharmacists.

“I was interviewed by one member of the board, who was not a pharmacist but was the lay person on the board and by the board’s attorney. The non-pharmacist board member was very incensed over the error, even though the patient was fine, no excess illness or injury had occurred, and recovery was complete. After the non-pharmacist board member chastised me for 10 minutes, I was told a formal reprimand would be put in my file.

“The lawyer, in retrospect, gave me bad advice. If nothing else, I was a good soldier who took a hit for the team.”

[15] Pharmacist misinterpreted directions for antidepressant Merital

“Worst mistake: Merital 100 mg every morning and 2 p.m. I took it as 1 in the morning and 2 in the evening. Should have been 1 cap in the am and 1 cap at 2 p.m. I think she got sick, but didn’t go to hospital. Anyway, they still traded with me.”

[16] Pharmacist dispensed wrong dose of penicillin 

“Luckily in 26 years I haven’t personally made too many big ones (that I know of). But funny, I do remember my very first — wrong strength of penicillin for a pregnant lady. That one worried me more than most, and every penicillin I fill reminds me of that one so many years ago.”

[17] Pharmacist did not catch wrong dose of antibiotic gentamycin 

“I guess I should be taken to the whipping post too. My worst error was when I was an intern (40 years ago). Gentamycin dose of 39 mg. Didn’t catch that it was for an infant. No harm done, but I never forgot it.”

[18] Pharmacist failed to catch technician’s error involving ibuprofen and generic Darvocet

“I just finished reading your article in Drug Topics entitled “My Most Serious Pharmacy Mistake”. I have been in practice for 27 years, all of which have been spent at XXXXXXX.

“In my time, I have had the opportunity to perform in a variety of roles ranging from inpatient pharmacy, nursing home pharmacy, home infusion and ambulatory pharmacy. I am currently in a leadership role with responsibilities on the ambulatory side.

“Although I literally recall every error that I have made, I wanted to share with you an instance that happened around fifteen years ago that is particularly poignant in my mind.

“I was working on a Saturday at one of our clinic pharmacies which is part of a hospital campus and it was a particularly busy day. The hours of operation were from 9 am to 12 noon and staffing was limited to myself and a pharmacy intern. In the three hours we filled 83 prescriptions and were also delivering medications to the floor for the patients being discharged.  

“Additionally, we have a fairly extensive front end, so there was much activity with patient purchases and medication pickup.  

“I provide these details not as an excuse but just for background.  

“The error revolved around two prescriptions that were for an OB patient being discharged following delivery. The medications were ibuprofen 800 mg and generic Darvocet N-100.  

“What occurred was that the labels were correct but the pharmacy intern had mistakenly filled both bottles with ibuprofen. In my verification, I failed to open the prescription vials and inspect the contents. 

“The error was caught when the patient noticed that the tablets in both bottles were identical. Despite acknowledging the error and agreeing to personally deliver the correct medication to the patient’s home, the patient was extremely irate. She threatened to sue me and said that she would notify the State Board of this “awful and unacceptable error”. She said that I had no business practicing pharmacy and that I should find another career.  

“Ultimately, the threats turned out to be empty as nothing further happened; however I have never forgotten the incident.  

“Like you, my internal punishment when I make a mistake serves as a wake-up call and helps to make me a better pharmacist and person.

“I do think that, by and large, pharmacists are cognizant of the innate unacceptability of errors in our profession and would work to correct any shortcomings following a mistake. As a leader, I encourage staff to report errors and near misses so that we can work to identify root cause and implement steps to mitigate future events.”

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