Picking Up the Right Patient's Prescriptions

Republished September 9, 2024

A pharmacy technician at a retail pharmacy gave the wrong prescription to a woman picking up medicine for her husband. The pharmacy uses a bin system for prescriptions awaiting pick-up and the technician accidentally grabbed the prescription in the bin next to the correct one. The first name of the two patients was exactly the same.

The woman knew the name of the medicine and the strength that her husband was taking. The drug name and strength that was in the other patient’s bag, lisinopril 20 mg for high blood pressure, were what she expected to see since that was the same medicine her husband was taking. 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 in for that refill. 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 other person's lisinopril prescription was returned to the pharmacy and the new prescription was filled for 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, open the bag while you are still at the pharmacy and read the name of the person that is printed on the label. Make sure all other information is correct.

Below are some other tips to consider when picking up prescriptions at the pharmacy:

• 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 medicine?" "I'm also taking_____, which I got at another pharmacy. Can I take both safely?"
• Every time you pick up a prescription, whether it is new or a refill, take it out of the bag and read the label. Is your name correct?Is your doctor's name correct? A misspelled name could mean you have someone else's prescription.
• Read the directions on the label. Make sure it is 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 are still in the pharmacy, read the drug information sheet stapled to the bag to learn what the medicine is supposed to treat, especially if it is a new medicine. Is that what you are being treated for? If not, it could signal an error, so check with your pharmacist.
• Read about the possible side effects. If you are picking up a refill and you realize that you have been having these side effects, tell the pharmacist immediately. He may want to call your doctor. If you are 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 are used to. But mistakes are possible, so check with the pharmacist to be sure.