Wrongly labelled medicines picked up from pharmacy.

[Katshouldnotswim]

MIL has just started taking tablets to help with her recent dementia diagnosis.

Just picked up the prescription from the pharmacy and noted that the label ( the pharmacy sticks on ) on one of the boxes isn’t what’s inside.

This is bad isn’t it

This happened to me a few years back. I was meant to get antibiotics but was given diabetes tablets. I noticed on day 3/4 the pharmacy were very apologetic and sorted it. It was a nightmare because I had to have an ECG and take the morning after pill because of side effects of what I had taken. Fortunately everything was fine

@RuthW

It happens. Take them back to the pharmacy. It may be the same drug but a generic version.

Occasionally the wrong drug does make it's way out we are all human.

It SHOULDNT happen. There are very strict rules and regulations for pharmacies. If the mistake is caught before the drug is handed over then it is classed as a near miss and recorded for training purposes, if the drug is actually handed over then it has to be reported and investigated and the pharmacist is at risk of being struck off depending on the severity of the mistake. What is written on the labels is also very important and MUST compare to the prescription and have clear instructions on how to take the medication. Clopidogrel and Sertraline are very different medications!

The process is very clear.
The drug should be compared against the prescription, checking the name, strength and quantity. The label is then compared checking the name of the patient, the drug, quantity and strength plus the dosage instructions, then it is applied and initialled by the dispenser.
It is then checked again in the same manner by the pharmacist.
If it is done by a big chain it is also likely have been scanned through a system to check the drug compares to the script.
It is a stackable offense to hand out wrong or wrongly labelled medication and the pharmacist can face legal ramifications too.
Please please report this so it can be dealt with properly

That potentially could have been a serious error if the label had been right but the medication wrong! Definitely needs reported, although not much will change it'll just highlight the error so hopefully won't happen again.

I once went into Lloyds to collect my medication, the pulled out the bag of meds, asked my address and checked the label and handed it to me. I knew it didn't feel right so I looked at the label and it wasn't even close to my address!! Clearly just asked out of habit and didn't even check!! Same surname but nothing else!! The pharmacy technician didn't even flinch, muttered sorry and scurried off! Not good.

@Katshouldnotswim I just couldn't believe how blasé they were about it! My Mum has several different lots of medication each day. The one's she was mistakenly given were for an Asian gentleman, and were heart tablets. They may not have caused many issues if taken alone but could have counteracted with the medication she's on. Not good!

This happened to me a few times, except the labels would be right but the tablets would be wrong. It was usually "just" the dosages that were wrong, but they were very wrong (50mg instead of 150mg). I changed pharmacy in the end as I didn't trust them anymore.

You can report them to the General Pharmaceutical Council (IIRC.) I did this when I got the wrong dosage of medicine for the second time. The first time I spoke to the pharmacy but when it happened again felt I had to report them so it didn't happen to someone else. They get a rap over the knuckles and have to undergo a bit of re-training. It's easy to do and they won't even know it is you if you don't want.

As someone else said it's a dispensing error once it's left the pharmacy! They have a procedure which includes checking no harm has been done and apologising/asking if you want to make a formal complaint.

From what you have said you now have a box of Clopidogrel with no dosage instructions on? Please go back to the pharmacy - they need to know and make sure adequate training is in place/that staff aren't so overworked that they are not checking properly etc.

I was given the wrong dosage of my asthma medication. It was double the dose of steriod preventative than I should have received. I found out after I got home and unpacked the bag. I went straight back and the pharmacist said oops, sorry, we have a new pharmacist and he got it wrong and gave me the correct dose. I was upset that she blamed the new bloke and really wanted to ask who did the counter check because if they were both new then that could cause very serious issues, but she was already walking back into the pharmacy and I didn't want to cause a fuss with 20 other people in the queue in the car park (covid rules) I was never asked if I wanted to report it so I guess they never declared the mistake.

The bad thing about it was the higher dose really affected my heart which is why I am not on it so if I had taken it and not noticed, I would have ended up in hospital again with sinus tachycardia

@Salaman

You can report them to the General Pharmaceutical Council (IIRC.) I did this when I got the wrong dosage of medicine for the second time. The first time I spoke to the pharmacy but when it happened again felt I had to report them so it didn't happen to someone else. They get a rap over the knuckles and have to undergo a bit of re-training. It's easy to do and they won't even know it is you if you don't want.

Who do you think retrains them?

Please complain and ensure it is followed up, a key pharmacy process has not been followed and this needs to be rectified.

Lucky for your Mum, you are vigilant and have spotted the error for her. Many others won't be so fortunate and a serious problem could result.

The process of accuracy checking for all dispensed items should have made this mistake impossible so the correct process has clearly not been followed.

Here is an example of an accuracy checking standard operating procedure document
https://dispensingdoctor.org/wp-content/uploads/2014/09/1D-accuracy-checking.docx

The pharmacy needs to review its accuracy checking practice and identify what happened so that they can ensure the proper procedure is followed every time.
.

This has happened to my DH before. I can't remember what he was given but it was definitely totally wrong and potentially lethal.

This is bad isn’t it

Yes.

I was given the wrong medication once. I had taken a couple of warfarin, instead of an antibiotic. I was told off by the shop assistant saying “it’s up to the customer to check their medication before taking it”.

I didn’t check it, I just assumed that because the printed label said fluxiclin, the contents were as well.

The pharmacist was helpful about it though, gave me the right medicine. Apologised.

Talk to the pharmacist and get another label printed.

This happened with my late mother's medication. The boxes of Digoxin had the right amount (higher than my mother's prescription) on them, but the pharmacy labels were for the lower amount that she should have been taking. Both boxes had been initialled by the pharmacist and by someone else who checked them. I only discovered them by my mother's bed ten days after she had started taking them and had become extremely ill and was in hospital. They then diagnosed Digoxin poisoning. It did actually shorten her life, though that could not be proved.

What I discovered, which was really shocking is that pharmacies have no obligation to report mis-dispensing errors either to their governing regulatory body, General Pharmaceutical Council, or the NHS which prescribed the medicine in the first place. It is all voluntary if these incidents ever become known. A real loophole.

A woman in my town died of digoxin overdose because the pharmacist misread the decimal point on the prescription and dispensed a higher dose.

Small mistakes can have big consequences which is why it needs to be reported.

A mistake should always be reported. Pharmacists and dispensers are human so mistakes will be made but if members of the public bring any to their attention they can and ought to learn from them. Most companies will have a very strict procedure so that they can report the error to their head office and sometimes you will receive a call from their head office with regards to it. They will also be asked to look at their procedures and how the error occurred and put more safety procedures in place, so segregating stock that comes in very similar packaging, re training staff, looking at staffing issues etc. Noone should ever be blasé about an error!

Absolutely take the medication back to the pharmacy, show them and complain. They should add a note on the patient's medication too so that they can be extra vigilant as well as reporting it, informing the team and changing their practice.