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Reporting a Medication Error

Transferring prescriptions between pharmacies requires caution

8212207f146778f83156ffc204ca380c MMost prescriptions can be transferred between pharmacies in the US. You may need to do this for several reasons:

· You are moving to a new location

· You are looking for a more convenient pharmacy location

· You recently made changes to your health insurance that require you to use a different preferred pharmacy

· You need to obtain a temporary supply of your medicines because you did not bring enough with you while traveling

But take care, as errors have happened when transferring prescriptions between pharmacies.


One mistake was recently reported by a consumer who had just moved to a different state. She asked that all of her prescriptions be transferred to a new pharmacy located close to her new home. After receiving the transferred prescriptions, the new pharmacy mistakenly filled a medicine that had been stopped by her doctor more than a month before. The medicine was a cholesterol-lowering agent, rosuvastatin (Crestor), that had been stopped because it caused very bad muscle pain, muscle tenderness, and fatigue. These could be signs of a serious side effect of certain cholesterol-lowering medicines leading to a muscle disease called myopathy.

In another case, prescriptions were transferred to a preferred pharmacy when a consumer’s health insurance changed. The consumer had type 2 diabetes and was currently taking oral metformin and injectable Trulicity (dulaglutide) to keep his blood sugar under control. Three months before this, his doctor had switched him from the oral tablet, Januvia (sitagliptin), to the injectable Trulicity. But when the man picked up his medicines the first time at the new pharmacy, he failed to notice that prescriptions for Januvia, metformin, and Trulicity had been filled. Fortunately, he noticed the mistake after he arrived home. If he had taken Januvia, metformin, and Trulicity together, he could have developed a dangerously low blood sugar level.

Other consumers have reported missing medicines when transferring all their prescriptions from one pharmacy to another. In these cases, the new pharmacy failed to fill an active prescription. These errors resulted from problems with the prescription transfer process or by simply overlooking one prescription among many that were transferred.

Here’s what you can do: If you are transferring your prescriptions from one pharmacy to another:

· Update your medicine list with your doctor and pharmacist before you ask to have your prescriptions transferred.

· Make sure you have enough medicine to last for as long as it may take to find a new pharmacy. You may want to visit a few pharmacies (and speak to the pharmacy staff) before choosing one.

· Be aware that some prescriptions cannot be transferred without a new prescription or if you are out of refills. If necessary, contact your doctor for a new prescription to be sent to your new pharmacy.

· Give your updated medicine list to the new pharmacy, and ask your new pharmacist to:

o Compare the transferred list of medicines with your medicine list

o Contact you for any clarifications

o Set up an appointment with you for a full medicine review to check for potential drug interactions, see if you are taking medicines with duplicate effects, and check on prescription refills

· When you first pick up your prescription medicines at the new pharmacy, ask the pharmacist to go over each one with you. Be sure you discuss the reason for taking each medicine, the dose, and how to take each dose. If you have any questions, ask your pharmacist or doctor.

· Always read the full label on prescription medicines before taking (or giving) them to verify that the medicine and dose is correct, the directions for use match what your doctor told you, and that the medicine is intended for you.

· If you are moving, ask your current doctor for new prescriptions with enough refills to last for 6 months. This will give you time to find a family doctor in the new area.

· Share your medicine list with your new doctor.

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