Pharmacy majorly screwed up-complain or not? Any pharmacists offer some insight?

[BarnacleNora]

On Friday I realised that the SSRIs I had been taking for the past almost two weeks were in fact an antacid type med for ulcers. The pharmacy had dispensed three boxes of this antacid instead of my ssri, labelled it with my prescription label and I had collected it and started taking it. Ironically I am already on a similar type of medicine, so my stomach has been double dosed for a couple of weeks!

I would have noticed sooner except unfortunately the first box I pulled out of the bag was a generic white cardboard one, the kind they usually use when they’re using blister packs from an incomplete box I imagine. So it was a white cardboard box with my label on and the blister packs inside. I didn’t even think to check the blister packs (the medication names are similar. Not identical and not really within reasonable doubt but start with the same letter and same sort of length of word, both end with an e so if you were glancing at the foil packaging and saw P———e that would probably be enough for your brain. Clearly it was for mine and tbh although I usually do a quick double check of the dispensing label I don’t tend to forensically check my prescriptions because….well because maybe naively I trust that there are safeguards in place to ensure I’m getting the right things. Much like I wouldn’t google which meds the gp had prescribed for an ear infection, I trust the professionals to carry out these processes)

I use one of those daily med organiser things because I never remember if I’ve taken them, so Friday night I went to sort out my tablets for the following week. It was then that I realise the error because I pulled out the next box from the pharmacy bag and this was branded, very clearly the wrong stuff.

Now…..I’ve been going through hell the last week and a half. Brain zaps, tinnitus, stomach upset. Mental darkness and awful thoughts like you wouldn’t believe. I even told my mum it was like an extreme version of titrating off SSRIs but it couldn’t be that because I wasn’t titrating. I was becoming really frightened there was something very very wrong, especially the brain ‘zaps’ (for those who don’t know, when you withdraw from SSRIs, even if it’s done incredibly slowly and carefully, you usually get these jolts across your brain and end of fingers, eyeballs etc that literally feel like zaps of electricity. But across the brain is worst it’s like an electrode stuck in the middle of your brain every time you move your head). I thought I was taking the right things and doing the right things so why was I getting these awful symptoms and why was my mind increasingly becoming so dark and back to a mental state that I’ve fought very hard not to be in (and haven’t been in since I’ve had children, that was really frightening, that I was getting that ill and now I had children to look after and protect).

Anyway. Went in today (sat morning) to address this with pharmacist. She replaced my meds immediately and apologised. Told me that she would inform my gp first thing Monday and that there would be a full investigation to find out what happened. She offered to give me details if I wanted to lodge a complaint. She was calm but serious. My mum (who I love dearly but is a very different person to me) would probably not have been impressed by the lack of grovelling or abject horror but I felt that she was probably paddling frantically underwater (I would have been)

However, she did say when I asked how it could have happened that it would have been ‘human error’. I asked if it was the case that two people had to check everything before it went out as that was what I thought had to happen in order to prevent these types of human errors. She said she could only see one tick and initial but she didn’t seem that shocked or upset that this was the case?

I left it there as I was desperate to get home and get on with replenishing my serotonin. I’m not convinced complaining will be entirely useful but I would like to know the outcome of the investigation and how they are going to stop this happening again. I was going to email the pharmacy to this effect.

Is this the right thing to do? Would a complaint actually be more beneficial or just increase the pressure on a small community pharmacy and deplete their resources further? I’m mainly asking people in this sector who might know really. I’d be reassured by a report from them but I guess a complaint would actually formalise what they have to do. But then what’s the use of formalising procedures to improve if a complaint ends up closing them down? I really don’t know how it works.

Sorry this has been really long winded. I’m well aware that this could have been infinitely worse, I could have been prescribed something that killed me. I was very lucky not to have more serious effects (mentally and physically) from a complete and sudden stop from a very high dose of ssri and then go cold turkey for two weeks without understanding that was happening to me. I do not want to downplay this and am not holding back from complaining because I don’t want to hurt any feelings. I just don’t know what would be the most productive course of action to take.

Thank you to anyone who can help on this!

You absolutely need to complain & take this further. This is really really serious.

www.pharmacyregulation.org/patients-and-public/reporting-concerns

Please report. This is a serious error that needs to be investigated.

Definitely complain. Those kind of mistakes can be life threatening. It was horrible what happened to you. There are some meds where if the wrong person took even one dose they could potentially pass away.
Complain to the British pharmaceutical council, I think it's called that. And ask your GP to switch you to another pharmacy. I hope there is one nearby? If not you can use an online service to have the meds delivered to your home.

Wow that's so dangerous, report!

As someone who used to work in care, it’s always wise to check the medication before you leave pharmacy.
Errors shouldn’t happen, but they do.
Unless in a predosed system, ready to go

You have every right to pursue a negligence claim here - was it a large chain or independent (no need to name)?

As others have said, there is a double check in place which they have failed to undertake and you have suffered for it - don’t be tempted to ‘feel bad’ for the individuals - it’s likely they are overworked especially if it’s a corporate. Every time I’ve been in a pharmacy recently it’s been some form of chaos and can’t help but overhear others reporting errors, though not as serious as yours.

It doesn’t matter that pressure the pharmacy is under. Reporting a mistake could be a flag they need to someone who is under too much pressure who needs some help or time off. Either way, you are doing your fellow medication takers a disservice if you don’t take it further, and I would encourage finding whichever governing body they have to be the place to do it, not just at a local level.
Also let your GP know, both for the side effects you experienced and for keeping an eye on other patients who suddenly have inexplicable weird shit happening to them.

I hope you’re feeling better soon OP, you must feel very let down. A lot of trust is placed in us as pharmacists and this experience will have damaged that trust.

If you are not satisfied with the results of the investigation, then I would urge you to take it further. A red flag would be the pharmacy/pharmacist brushing the incident under the carpet and not being open about investigating it, and/or trying to shut you down or make you feel silly for feeling upset. They should welcome as much information as possible from you including how you physically suffered but also how it’s left you feeling emotionally.

The regulator for pharmacies and pharmacists is The General Pharmaceutical Council.

You may also want to consider if you could have a clinical negligence claim.

This type of incident is a pharmacist’s nightmare (of course this rightly won’t be a concern of yours, but just giving a point of view). I can all but assure you that it will have been taken very seriously. It sounds as if the interaction with the pharmacist was professional and as constructive as possible at that time, and she remained calm and factual when looking at the item in question. I don’t think anything else could have been expected just then, especially prior to the investigation. Apologising, supplying the correct item, and making it clear it will be investigated is a standard approach. If you feel there was a distinct lack of empathy that compounded this awful experience, please share this with them or the company.

The investigation may prompt a warning sign near “look alike sound alike” drugs involved - these already exist in a lot of pharmacies but are often reserved for the more toxic/high risk ones e.g. quinine for restless legs Vs. quetiapine for psychosis. However, an incident of this nature should inform the way things are done going forward, and personally I would certainly look to implement this in my pharmacy if it wasn’t in place after an error like this. Retraining a particular staff member may be needed if the error was a case of a process not being followed correctly (such as not ensuring a second check), or possibly re-writing the existing standard operating procedure to improve patient safety. Errors/a single error may contribute to the owners looking at investing in new technology which reduces the risk of errors.

There is a fair likelihood that this really was a human error and the dispenser picked the wrong drug off the shelf, then the pharmacist didn’t spot it. There could be several things that contributed to such a thing nevertheless, such as the physical arrangement of drugs of the shelf, staffing levels, whether adequate breaks were taken, etc.

I think it’s worth saying that pharmacies and pharmacists are often under a lot of pressure, much of it behind the scenes/not obvious, and are dispensing medication around other tasks, such as vaccinations, assessing patients with various ailments then providing treatment along with the very laborious paperwork that goes along with that, taking phone calls from the public and local GP surgieries regarding item availability, clinical queries and advice for minor illness, providing emergency contraception, checking blood pressures, supervising the consumption of methadone, and lots more, not to mention the huge problems with stock not being available from the wholesalers and the rising rates of theft and violence affecting retail generally. I say this, not to excuse or minimise what happened to you in any way, but to paint a realistic picture of a day in a pharmacy which is more multifaceted than many imagine. Any investigation must give thought to the way all of these tasks are managed and try to make improvements.

Just to add to my comments on the pharmacist’s handling of the situation, I am sure the following doesn’t apply to you, but I have had situations where an accusation of a dispensing error has been made against a pharmacy I’m working in, and it’s turned out that no dispensing error had been made by the pharmacy. Therefore I find it best as the pharmacist to make no assumptions until after the investigation. (Examples of this type of thing are: the item was from another pharmacy/dispensed several years ago and retrieved from the person’s cupboard in error/the patient had the correct item dispensed but had emptied the box of its contents and refilled it with the blister packs of another medication by accident).

I hope you recover in every way OP and that you have found my answer helpful. All the best to you.

Thank you to everyone for your responses, pretty much unanimous! To be clear, I would have no hesitation in complaining if it was the right course of action (and clearly it seems to be) but I wanted to double check that the process would actually be productive and impactful rather than heap more work and possibly an overload of scrutiny. Sledgehammer cracking an egg kind of situation. Probably because my background is in education and our regulating body isn't exactly the most helpful or constructive in its approach to failing or struggling schools. I didn't know if this was going to be a similar situation.

@OohCrumbs your post in particular was really helpful. They are a small community pharmacy and I bear no individual there any ill will. For four years now they have been brilliant and earlier in the week when I cried all over them because of the adhd meds shortage (which seemed like an oddly over emotional response for me, now I know why!) they were bending backwards to try and cobble together as lasting a supply as they could, despite their 'whiteboard of doom' of all the supply issues and shortages you can see at the back of the shop. In many ways it's almost more disappointing that someone or something has let them down like this rather than a more anonymous big chain because they do all seem to work very hard. It shouldn't have happened but I'm not out for blood. I just don't want this to happen to anyone else (and could have done without it happening the week I was trying to write job applications so we'll see if I actually get any interviews because god knows how well they ended up being written 😵‍💫)

Thanks again for reassuring me that a complaint is the right course of action everyone. I will look into it properly tomorrow

The fact is that they made two mistakes not one. First picking the wrong medication and then not completing the double check. That's either severe overwork or it's a major carelessness problem.

I'm glad you're going to make the complaint. This needs to be taken very seriously.

Yes complain. This is really serious, there's a good reason why you shouldn't stop taking SSRIs without the help of your doctor. 3 days without mine and I'm feeling a mess!

At least by doing this you can ensure there will be some retraining so it's less likely to happen again.