Picking up the right patient's prescriptions


A pharmacy technician in a chain retail pharmacy issued the wrong medicines to a patient. The pharmacy uses a bin system for prescriptions awaiting pick-up and the technician accidentally selected the prescription in the bin next to the correct one. The first name of the two patients was exactly the same.

The person picking up the prescription was the wife of the patient. By coincidence she knew that her husband also happened to be taking the same drug and strength that was in the other patient’s bag – lisinopril 20 mg, for high blood pressure. So she didn’t think anything was wrong. However, when she got home her husband remarked that he did not need any more lisinopril and did not call that in to the pharmacy. Actually, her husband had a hormone deficiency and was supposed to be getting a new prescription for testosterone cypionate injection, which he had been taught to self-administer. The lisinopril prescription was returned to the pharmacy for the correct medicine, testosterone.

The pharmacy has made several internal changes to prevent errors like this from happening again, including always asking for the patient’s full name and birth date. Some pharmacies may also ask for an address or phone number as part of the identification process. For everyone’s safety, be prepared to provide this information. If you are picking up a prescription for yourself or a family member at their request, ask for the pharmacy staff member or the pharmacist to open the bag while you are still at the pharmacy and have them read to you the full name of the patient as printed on the label.

For other important considerations when picking up prescriptions at the pharmacy, here are some guidelines:

  • When picking up a new prescription, ask the pharmacist at least one question about it. Here are some examples: "Is there anything special I should know about taking this medication?" "I'm also taking _____, which I got at another pharmacy. Can I take both safely?"
  • Every time you pick up a prescription, whether it's new or a refill: Take it out of the bag and read the label. Are your name and your doctor's name correct? Don't assume that any errors are just typing mistakes. A misspelled name could mean you have someone else's prescription.
  • Read the directions on the label. Make sure it's what your doctor told you, and that you understand how much medicine to take and how many times a day you should take it.While you're still in the pharmacy, read the drug information sheet stapled to the bag to learn what the medicine is supposed to treat. Is that what you're being treated for? If not, it could signal an error, so check with your pharmacist.
  • Read about the possible side effects. If you're picking up a refill and you realize that you've been having these side effects, tell the pharmacist immediately. He may want to call your doctor. If you're getting a refill, make sure the medicine looks the same as it did last time. If it looks different, ask the pharmacist about it. Most likely, the pharmacist has filled your prescription with a generic drug that looks different from what you're used to. But mistakes are possible, so check with the pharmacist to be sure.
Created on August 9, 2009

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