DH got prescribed the wrong dosage of pills - should we/would you take it further?

[IdrisTheDragon]

DH has migraines and takes 10mg of amitriptyline daily as a preventative measure.

I picked up his repeat prescription last week for him. On Saturday he was really tired, which is a side effect he gets from it, but he kept falling asleep.

This morning he was about to take one when he realised it that although the sticker on the packet said 10mg, the pills were 50mg.

There is a dispensary at our doctors' surgery, and so I took them back this afternoon, where they were extremely apologetic. Not sure whether we should do anything more about this (other than check our prescriptions very carefully). In this case there wasn't a problem (apart from very sleepy DH) but I do feel a little uneasy.

Yes, you need to take this further.

You were really lucky the only adverse reaction was that DH was quite tired...

Presumably it was still a pharmacist that dispenses the prescriptions? The Royal Pharmaceutical Society has a complaints department, and I would send them a letter.

Or a letter to the practice manager.

Either way, there should be systems in place to check prescriptions. It could have been much worse....

But glad your DH is OK

I would say take it further. I am a nurse and made a drug error once, and imo the reason to take it further is to ensure that safeguards are in place so that the error can't happen again (rather than as a "punitive" action)

I would suggest letter to practice manager initially (but do it promptly, i.e. tomorrow).

Did he get prescribed the correct dose but issued the wrong tablets? If so the pharmacist is at fault. If the prescription is wrong then the GP is at fault.

You may want to speak to the pharmacist/practice manager (depending where the fault originated) as they should carry out a critical incident analysis.

Good point Sidge.

Presumably if it was a repeat prescription, in other words, a regular one, then it would be constantly the same and since the pharmacist apologized, they admitted they were at fault?

I agree with onepiece - you don't want it as a punitive action, rather a remedial one....

He was prescribed the correct dosage but issued the wrong tablets.

I think I did talk the most senior pharmacist there and she said there is a system (which obviously failed on that occasion) of having two people checking that the correct pills have been supplied.

Thank you for your thoughts - I don't think DH would be inclined to take things further though - probably/possibly because we are often in there and they "know" us (know our names anyway ).

I am veering towards doing something though.

Well, it's fine having a system in place, but if the system isn't working, then it needs to be reviewed.

Could you just mention it to someone in the surgery unofficially if you don't want to make it official?

Obviously you realized the mistake quickly and are intelligent enough to know that something wasn't right, but what if it happened to someone who wasn't as bright as you?

That's what I'm thinking really - DH is fine but someone else might not be.

(Not sure entirely how intelligent DH was being as he said a bit ago that "the tablets looked a lot bigger" but didn't really think much more about it).

Yes, do take it further - make sure the GP and the practice manager are aware. Sidge is right, the practice should be performing a critical incident analysis to find out how on earth this happened and how to make sure it doesn't ever again.

Luckily dh was OK but the next person might not be so fortunate.

A pharmacisst fucked up my repeat prescription once. Could have been very serious indeed had I not spotted the error. I made sure the GP and PCT knew about it as the pharmacist was very obstinate and refused to re-issue the drugs.

I agree with sidge.

The issue should be drawn to the attention of the senior pharmoacist and practice manager.

A critical incident has occurred and needs to be investigated and discussed by all concerned to make sure that there are safeguards in place to prevent it happening again (and potentially being a lot more serious).

All pharmacists who practise in Great Britain have to be registered with the Royal Pharmaceutical Society of Great Britain and all registered pharmacies are inspected by the Royal Pharmaceutical Society of Great Britain. The RPSGB is responsible for ensuring that all pharmacists and pharmacy owners act in accordance with the Code of Ethics and with the laws relating to medicines and poisons.

The Society can deal with:

complaints about the professional service provided by a pharmacist/pharmacy at all levels of healthcare, eg, a dispensing* error, wrong labelling, or out of date medicine supplied

RPSGB complaints form

fwiw i would complain

This happened to me once but it was the GP pharmacy which gave ds the wrong drug. Luckily I queried it as didn't recognise the ingredients. They were v. apologetic but I didn't take it further as no harm done.

I do see, however, why so many posters are saying that you should kick up a fuss, obviously it could have caused a major problem.

this was a near miss and should be documented so they can look at thier system, checks and balance. it failed

on this occasion no harm done

BUT nonetheless do draw to their attention