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Reporting a Medication Error

Mystery Tablets and Capsules Found in Prescription Containers

Published May 11, 2023

We often hear from consumers who find one or more different tablets or capsules mixed in their prescription vial. For example, a young woman was prescribed metformin 500 mg to treat high blood sugar. Several days after starting the medicine she noticed two differently shaped tablets in the container. One was a small, round tablet which was the metformin she was prescribed to take. The other tablet was oval and had the markings “G 13” imprinted on it; that tablet was gabapentin 800 mg (Figure 1, left).In another case, we heard from the daughter of an elderly woman who was prescribed Eliquis (apixaban) to treat blood clots. The woman had found a large, white tablet mixed in with the Eliquis tablets, which are small and yellow (right). The white tablet was later identified as Soma (carisoprodol), a medicine used to treat muscle pain and spasms. While we are uncertain of what causes these mix-ups, we suspect that tablets or capsules occasionally get stuck in the counting machines that pharmacies often use to count tablets.

Figure 1 (left). Prescription vial with two different tablets. The round tablets were the correct, prescribed medicine, but the oval tablets were a different medicine. Figure 2 (right). Large, white, round tablet found mixed in with yellow tablets.

Here's what you can do: When picking up a new (or refilled) prescription, open the container and look at the contents before leaving the pharmacy. Confirm the tablets or capsules are identical and the medicine you received is correct. You may not be able to see all of them when checking at the pharmacy, so always look at the medicine tablet/capsule before you take it. If it is different from what you expect, do not take it. Contact your pharmacy if you find a medicine tablet/capsule in your prescription vial that is different from the others.

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