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Reporting a Medication Error

Double Check Prescription Medicine Dispensed in a Manufacturer’s Container

Figure 1. A patient was prescribed lisinopril/hydrochlorothiazide, but the pharmacy dispensed a manufacturer’s container of lansoprazole (left). In another case, a patient was prescribed rosuvastatin 20 mg, but they received a manufacturer’s container of rosuvastatin 10 mg (right).

Published July 25, 2023

Sometimes, a pharmacy may dispense your prescription medicine in the original sealed manufacturer’s container instead of the familiar orange plastic container. This may happen, for example, because the medicine is light or moisture sensitive and should not be opened until it is ready to be used. Or the manufacturer’s container may simply contain the exact amount needed to fill the prescription.

However, just because the pharmacy did not transfer the medicine to a new container does not mean an error will be prevented. We have received reports from consumers who received medicine in the original manufacturer’s container, but it was the wrong medicine or, it was the right medicine but the wrong dose. For example, a patient was prescribed a combination medicine used to treat high blood pressure (lisinopril/hydrochlorothiazide). Instead, the patient received a manufacturer’s container of lansoprazole, a medicine used to treat heartburn (Figure 1, left). Another patient reported a dosing error. They were prescribed rosuvastatin 20 mg to treat high cholesterol. However, they received rosuvastatin 10 mg (Figure 1, right) in the manufacturer’s container.

Figure 2 (left). The expiration date on the pharmacy label did not match the expiration date on the manufacturer’s container. Figure 3 (right). When checking your prescription medicine, make sure the tamper-evident foil seal is intact. The image above shows a seal that was already opened when the patient received the prescription from the pharmacy.

Here’s what you can do: If you receive your prescription medicine in its original container, check to make sure the medicine is correct. Know the name of the medicine and dose prescribed by your doctor. When you pick up your medicine at the pharmacy, look at the label to verify you received what the doctor prescribed. Check that both the pharmacy label (attached to the manufacturer’s container) and the name and dose of the medicine on the manufacturer’s container match and are what you expect. If the pharmacy label covers the name of the medicine and dose on the manufacturer’s container, ask the pharmacist to confirm that the medicine is correct. Make sure the expiration date on the container matches the expiration date on the pharmacy label (Figure 2). Verify the tamper-resistant seal is intact (Figure 3).

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