I Was Given the Wrong Rx. How to Stop a Pharmacy Mix-Up from Happening to You

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Two weeks ago, I called in a refill of a medication I had recently started taking. Then the pharmacist left me an urgent voicemail asking me to call her “right away.” When I did, she gave me some seriously unsettling news: I had unwittingly been popping the wrong medicine—one with a very similar name to the drug I had actually been prescribed—for four weeks.

You know how prescriptions are supposed to work: Your doctor pulls out his pad or e-prescribes your Rx. Either way, the pharmacist fills one of those little orange bottles with your correct medication, in the proper dose.

But that’s not always what happens. An overworked pharmacist could misinterpret your doctor’s messy scrawl (one woman we know was handed herpes medication instead of her lupus drug), accidentally give you an Rx meant for another patient with a similar name, fill the bottle with 250 mg pills instead of 25 mg ones, or print a label instructing you to take the medicine too often—or not frequently enough.

The impact of mine, luckily, was pretty minimal. Both drugs (the one I was taking and the one I was supposed to be on) work in similar ways. I hadn’t received a dangerously high dose. And the condition I was treating—recurrent kidney stones—was not life threatening or even particularly urgent.

But pharmacy errors can have serious, even fatal, repercussions. The family of a Florida woman won more than $33 million in 2010 in a wrongful death lawsuit against a national drugstore chain. The pharmacy had allegedly dispensed her blood thinner for breast cancer at 10 times the correct dosage, leading to a brain hemorrhage that forced her to stop the cancer treatment.

In another case of mixed-up meds, a different national chain apologized for doling out the breast cancer drug Tamoxifen to some children in New Jersey who had been prescribed fluoride (fortunately, nobody was seriously harmed).

So what can you do to protect yourself? Follow these simple steps from pharmacist Allen Vaida, executive vice president of the Institute for Safe Medication Practices (ISMP), a nonprofit dedicated to preventing drug errors.

In the doctor’s office

1. Know exactly what you’re on. “Electronic prescribing is a good thing in that it’s decreased a lot of errors with penmanship,” Vaida says, “but on the downside, patients don’t have any paper copy of what they’re supposed to be getting.” Always ask your doctor to write down the name of the drug (and its generic version), the dosage, and any instructions.

2. Make sure your doctor includes why you need the med. The name of your medication may be super similar to that of another drug, but if one treats high blood pressure and one anxiety, your pharmacist will know which is for you. (And you can double check with this handy chart of confused drug names.)

At the pharmacy

3. Open the bag. “Don’t walk out with the bag still sealed or stapled,” Vaida advises. “It’s one of the simplest things you can do, but we’ve found that it can prevent more than 50 percent of errors.” If you see another patient’s name on the label, or the pills look different than you remember, stop and ask the pharmacist to review it.

4. Stop and chat. Pharmacists are required to provide medication counseling for Medicare patients; in some states, this consult is mandatory for all. Still, “sometimes people will sign off without actually receiving it,” Vaida says. “But counseling is often what will flag an error, especially with a new prescription. The pharmacist might say ‘So this is going to help control your diabetes,’ and the patient responds, ‘Huh? I don’t have diabetes.’” Many drugstores now have a private area, so you don’t have to ask about your yeast treatment with a line of people behind you.

Back at home

5. Be alert. If your meds taste different than you expect, or you have the wrong number of pills, call the pharmacy. And definitely speak up if you notice unexpected side effects or the drug doesn’t seem to be doing the job (for example, that rash won’t clear). You can also check the National Library of Medicine’s Pillbox (pillbox.nlm.nih.gov), which allows you to search drugs by name, imprint (the series of numbers or letters imprinted onto the tablet), or appearance.

6. Blow the whistle.

So what should you do if you a drug mix-up happens to you? Alert both the pharmacy and your physician—even if the mistake was a minor one. “You want them to look at exactly what happened, and make sure it doesn’t happen again,” says Vaida. Also report the incident to your state pharmacy board, as well as the website consumerdrugsafety.org, which is run by the ISMP. “When we see that there’s an error that keeps happening,” he says, “we work with the FDA and the drug manufacturer to help get the labeling changed.”

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