Published May 13, 2025
A doctor prescribed phenazopyridine for a person who was having pain and burning with urination. Unfortunately, the person accidentally took too much of the medicine and was hospitalized with kidney failure. The instructions were to take one 200 mg tablet of phenazopyridine three times a day. But instead, the person took 2 tablets (400 mg) three times a day. This happened because of how the medicine was dispensed from the pharmacy.
The pharmacy did not have enough tablets from one manufacturer to fill the prescription, so they used phenazopyridine from two different manufacturers. They put the tablets from one manufacturer into one bottle and the tablets from the other manufacturer into a second bottle. The pharmacist did not speak to the patient when they picked up the prescription, so they did not know that they should finish the medicine in one bottle before starting the second. As a result, they mistakenly took one tablet from each bottle for every dose, which caused the overdose.
Sometimes pharmacies buy medicine from multiple manufacturers because of supply issues or costs. They try to use the supply from one manufacturer first, before opening the new supply, which is what happened in the event previously described. Some pharmacies combine tablets from two different manufacturers into one bottle, separating them with cotton, or using two separate bottles. However, when medicine is used from two different manufacturers to fill a prescription, it is important to clearly communicate this information when the prescription is dispensed. Sometimes pharmacies can partially fill a prescription until more stock arrives from the same manufacturer. Another option is to transfer your prescription to another pharmacy that can provide the full quantity from one manufacturer.
Here's what you can do: When picking up a prescription from the pharmacy, ask to speak to the pharmacist. Open the bag before leaving the pharmacy counter. Look at the medicine vials and read the label. Make sure your name is on the label and the name of the medicine you expect. If there is more than one vial with the same medicine, ask the pharmacist if you should take medicine from one vial before starting the next one. Ask if the vials can be labeled to show exactly how the medicine should be taken. For example, when using two bottles, pharmacies should clearly label them as “1 of 2” and “2 of 2” and explain this at pickup. Once home, check the medicine again to ensure that only one manufacturer’s medicine is in the vial. If something doesn’t seem right, contact your pharmacist.
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