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Reporting a Medication Error

Getting the Wrong Person’s Medicine at the Pharmacy: Easy Steps Consumers Can Take to Avoid These Errors

Published April 15, 2024

Giving a correctly filled prescription to the wrong customer is a common error in community pharmacies. If this has never happened to you, maybe you’re surprised by this fact. But you are more likely to be among the millions of people who have gone home from the pharmacy only to find they have someone else’s medicine inside the pharmacy bag.

Most people trust that the pharmacist will fill their prescriptions correctly. Based on a 2023 Gallup poll, Americans rate pharmacists as one of the most trusted professions. Yes, pharmacists deserve our trust. But they are human and could make a mistake, as could the person who rings up the sale.

How errors happen

Giving medicine to the wrong customer can happen for several reasons. First, a mistake can be made when placing the filled prescription in a bag for pick-up. These errors can happen when the technician or pharmacist is working on more than one person’s prescription at a time, and then placing the medicine in the wrong bag. Most people pick up their medicine and leave the pharmacy without opening the bag. Some pharmacies do not require their workers to open the bag prior to ringing up the sale. So, they do not look at each filled prescription in the bag when giving it to the customer to be sure it is for the correct person. People may notice the error once they get home, especially if the medicine looks different than last time. But others may not, and as a result, many people have taken the wrong patient’s medicine.

Another way a medicine can be given to the wrong customer is when pharmacy workers select the wrong bag of medicine. The process of identifying the customer can be incorrect if both a full name and date of birth are not asked for at the time of sale. Some pharmacy workers believe they know their customers by sight and do not have the safe habit of always asking customers to state their full name and date of birth. Or, caregivers, friends, and even family members who pick up prescriptions for someone else may not know the person’s date of birth. Then, the wrong customer’s bag may be chosen if there are medicines in the pick-up area for customers with the same or a similar name. Using an address to identify customers is not ideal, as people with the same last name often live together.

Consequences of errors

There are many ways that people can be harmed by this type of error.

Taking medicine that is not needed. If you do not notice the error and take another person’s medicine, it could be a medicine that should never be taken given your health conditions, allergies, or other medicines you are taking. For example, a pregnant woman was given a prescription for an antibiotic to treat an infection. She was accidentally given another woman’s prescription for methotrexate instead. Both women had the same last name and similar first names. The pregnant woman took one tablet of methotrexate before noticing the error. Methotrexate is a medicine used to treat certain cancers or other conditions such as rheumatoid arthritis and psoriasis. The medicine prevents cell growth and should never be taken by a pregnant woman. It can cause birth defects or a miscarriage. The pregnant woman was seen in the emergency department, but it was too early to determine if the unborn child had been harmed.

Omission of the correct medicine. Another problem with receiving and taking another person’s medicine is that you may not be taking the correct medicine that was prescribed for you. This can lead to untreated health conditions that can get worse over time or cause other adverse effects on your health. For example, a person who had been prescribed an antibiotic for a serious bacterial infection accidentally received another person’s medicine, sertraline (Zoloft), to treat depression. After 10 days, the person became very sick as the infection got worse since it was untreated. In another example, a person had been prescribed a pain medicine but instead received another person’s prescription for allopurinol, a medicine used to treat gout, an inflammation of the joints. After a few days without the pain getting better, they noticed the error and called the pharmacy to correct the mistake.

Misuse of the wrong medicine. Customers who are accidentally given the wrong person’s medicines have sometimes misused these medicines for recreational purposes or to harm themselves. In one case, a customer went to the pharmacy to pick up prescriptions for an allergy medicine and oxycodone, a powerful pain reliever. The pharmacy found that the filled prescriptions had accidentally been given to another customer. When this customer was called, they denied receiving the wrong prescription, presumably because oxycodone is a common drug used by people with a substance use disorder. In another case, a woman who had picked up a prescription filled for Premarin (estrogen) found another person’s medicine also in the bag when she arrived home. The medicine was amitriptyline (Elavil), a medicine to treat depression. Later, a pharmacist received a call from a local hospital indicating the woman was in the emergency department after taking 30 amitriptyline tablets that the pharmacy had given her in error. It appeared to be a suicide attempt.

Violation of protected health information. Another unfortunate part of this type of error is that confidential information is shared with the person who receives another person’s medicine. The full name and address of the person, along with the drug name, are on the pharmacy label. For sensitive medicines, such as psychiatric medicines or medicines that treat human immunodeficiency virus (HIV), people may be troubled that another person is aware of this information.

How to prevent harm

There are several steps people can take to spot this type of error and avoid potential harm from taking the wrong medicine or not taking the correct medicine.

  • Always provide the pharmacy with your full name and date of birth when picking up prescriptions. This is important even if you know your pharmacy workers well, and they know you.
  • Check the prescriptions your pharmacist has given you before you leave the pharmacy. Open the bag at the counter to view the medicine labels to be sure the medicine is for you and looks correct.
  • Talk to the pharmacist about your prescription medicines before you leave the pharmacy.

Here's what you can do:

Every time you pick up a filled prescription, whether it is new or a refill, doing these things before you leave the pharmacy can help prevent an error.

Open the bag. Take the filled prescription out of the bag to view the label. Are your name and your doctor’s name correct? Do not assume that any errors are just typing mistakes. A misspelled name could mean you have someone else’s prescription medicine.

Read the label. Read the drug name and directions on the label. Make sure it is what your doctor told you, and that you understand how much medicine to take and how many times a day you should take it. Review the tips on how to read a pharmacy label so you can verify that you have received the correct medicine and know how to take it correctly.

Check the reason. Open the patient information leaflet provided. Read the name of the medicine and what condition the medicine is supposed to treat. This information is usually found at the top of the page. Is the medicine what you expected? Does it treat your condition? If not, it could hint there was an error, so check with your pharmacist. (Read the full information leaflet once you are home and call the pharmacist if you still have questions.)

Check the appearance of the medicine. If you are getting a refill, open the bottle to make sure the medicine looks the same as it did last time. If it looks different, ask the pharmacist about it. Most likely, the pharmacist has filled your prescription with a generic form of the drug that looks different than the medicine dispensed before. But mistakes are possible, so check with the pharmacist to be sure.

Talk to a pharmacist. When picking up a new prescription, ask the pharmacist at least one question about it. Here are some examples:

  • Is there anything special I should know about taking this medicine?
  • Does the information sheet you gave me cover everything I should know?
  • I’m allergic to ______. Should I still take this medicine?
  • I’m also taking ______, which I got at another pharmacy. Can I take both medicines together safely?

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