Excuse me, I think there is an error with my prescription: Pharmacy staff should respond with honesty, compassion, and respect


Most people realize that errors can happen, including when getting a prescription filled at the pharmacy. Although pharmacists do their best, mistakes sometimes happen. Thanks to safer medicine labels and technologies like barcode scanning, mistakes of the past are rapidly declining. The few pharmacy errors that do slip by usually do not cause serious or permanent harm. Still, that is little consolation to a consumer who has been harmed or could have been harmed if a more serious error had happened.

ISMP receives reports directly from consumers about mistakes that occurred at their local pharmacies. They are understandably concerned about the errors. But surprisingly, the consumers who report errors to us are usually more upset about the response from the pharmacist or pharmacy management team than with the actual error itself. Based on what we hear from consumers, all too often, pharmacy staff, managers, and corporate personnel leave consumers dissatisfied when responding to medication errors. Here are a few examples of errors reported to ISMP by consumers who were dissatisfied with the pharmacy’s response:

I picked up a prescription for Restoril (temazepam) to help me sleep. The pills didn’t work, and I actually felt worse taking them. I only slept about 5 hours in total over the next 4 days. I had heart palpitations, chest tightness, and feelings of panic and agitation. Concerned, I brought the medicine back to the pharmacy. The pharmacist identified the pills as Adderall (dextroamphetamine and amphetamine), a medicine used to treat attention-deficit disorder (ADD), not Restoril. The pharmacist immediately became defensive and refused to answer questions about what I should do. He just told me I needed to switch pharmacies. I called my doctor, who told me to go to urgent care where I learned that my heart rate and blood pressure were elevated. The pharmacist at the store refused to file a claim to pay for my out-of-pocket costs, which aren’t significant, but they should do the right thing.

I received a call this morning from the pharmacy to inform me that my prescription was ready for pickup. I called the store and was told that the prescription was for amoxicillin (a penicillin-type antibiotic). I told the pharmacist that I was allergic to that medicine. The pharmacist made an “oops” noise and said she would return it to pharmacy stock. She gave me no explanation, no apology, and took no responsibility for the mistake.

I took my 7-year-old child to the doctor and received a prescription for a 5-day course of antibiotics, Zithromax (azithromycin) suspension (100 mg per 5 mL), to treat an inner ear infection. The doctor went over the instructions with me and included the directions on the prescription to take a 5 mL dose on the first day, followed by 2.5 mL doses once daily on days 2 through 5. After arriving home with the filled prescription from the pharmacy, I noticed that the directions on the bottle said to take 5 mL the first day, and then 2.5 mL on days 2 through 4. I also noticed that there did not seem to be enough volume of medicine in the bottle to last for 5 days, as the doctor had told me. I called the pharmacy to question the directions to give the medicine for 4 days instead of 5 days, pointing out that the directions on the bottle were different than the directions on the prescription. The pharmacist became defensive and told me, “We don’t make mistakes here,” suggesting that I just wanted another bottle of the medicine, which he could not give me. Although my child was not harmed by the error, I am concerned with the pharmacist’s denial of ever making a mistake and his inability to be open to learning from mistakes. Also, I am upset that the pharmacist showed no concern for my child, even when I said I was afraid about not giving him a full course of antibiotics.

While these responses are clearly not typical in all pharmacies, they suggest that some pharmacy staff have not been trained to respond properly when a consumer reports an error. When a medication error happens, especially a harmful one, pharmacy staff may feel extreme stress and anxiety. Fear of legal action may cause pharmacy staff to view the consumer as an enemy or threat. Instead of being transparent and honest about making a mistake and putting the consumer’s safety and interests first, they may deny making an error and feel the need to defend themselves. Unfortunately, this approach is not in the best interest of safety and often prevents the pharmacy staff from really looking into the factors that caused the mistake.

In some cases, pharmacy staff may truly want to be more responsive to consumers who report errors. However, they may be required to follow pharmacy policies that, due to legal concerns, may not encourage pharmacy staff to apologize for the error, explain how it happened, or share what will be done to avoid similar errors in the future.

Here’s what you can do: If you think there may be a mistake with your prescription medicine, don’t hesitate to let your pharmacy staff know, even if a prior experience has been unsatisfactory. Every pharmacy should provide clear guidance to its staff regarding how to respond to the customer honestly, compassionately, and fairly when a mistake happens. Thus, it is totally reasonable for you to expect the pharmacy staff to do the following when a mistake is brought to their attention:

· Make time to talk to you immediately.

· Treat you with respect.

· Acknowledge that a mistake has happened and offer an apology.

· Inform your doctor about what happened (especially if you have taken any doses of the wrong medicine).

· Advise you to see your doctor or go to the hospital (especially if you may have been harmed or put at risk by taking the wrong medicine).

· Investigate the causes of the mistake with your medicine.

· Come up with an action plan to avoid similar mistakes in the future.

· Let you know about the action plan and how it will be put in place.


Created on February 16, 2022

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