SeekerofTruth

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What's the biggest mistake you have heard occurring in retail pharmacy?
 

cellardoor6

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Med sold to wrong patient. Patient thought she was getting tramadol 50mg, received flecainide. She took the tabs Q 4-6 hours, had to go to the ER. Apparently patient did not see there was a different person's name and drug name on the label, didn't read directions either.
 

josh6718

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What's the biggest mistake you have heard occurring in retail pharmacy?
1. Pharmacist dispensed Ciprodex with directions to use in the eye.
2. Pharmacist dispensed a RX to a patient for warfarin that was called in for levaquin (not sure how this exactly occurred)
3. Pharmacist dispensed celoxicob instead of celexa.
4. Pharmacist dispensed levetiracetam instead of levocarnitine
 
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PolarPop

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A pharmacist dispensed lamotrigine 150 mg instead of lamivudine 150 mg. The patient only took a few doses though and nothing happened
 

rph3664

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A pharmacist sold dialysate instead of distilled water to a parent, for mixing baby formula. The baby died from hyperkalemia. :wow:

I was skeptical, because wouldn't the baby have refused it because it tasted bad? OTOH, apparently a newborn's taste buds aren't very well developed.
 

hye345

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This is one I did (and I've been licensed for less than 2 years): doctor sent a script for fluoxetine, I dispensed fluconazole. Patient was on it for about 3 weeks before bringing it back.... scared the hell out of me.
 

lord999

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What's the biggest mistake you have heard occurring in retail pharmacy?
Not going to top hyperkalemia kills the baby. UPS left a box of Depo-Provera out in the Phoenix summer sun for six hours before delivering it to the warehouse. That autumn (2003), there were about 16-18 known accidents where women got pregnant despite getting their Depo-Provera shots on time. The company spent six weeks frantically calling every single patient, and it was a nightmare to fix.
 

WVUPharm2007

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The "methotrexate subbed for fluoride numerous times" incident in Jersey has to be up there. It's the reason we have those stupid blue dustpans we have to pour every script through at CVS.
 

Sine Cura

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Contrave being dispensed to an opioid-experienced patient. The patient was using opioids illicitly and did not disclose that. The patient alleged precipitated withdrawal and ended up seeking medical attention for it. However the physician did write for Contrave + Norco simultaneously

Counseling burden does suck if you are the only RPH but I bet most of the above could have been caught if doing counseling
 

CetiAlphaFive

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A pharmacist sold dialysate instead of distilled water to a parent, for mixing baby formula. The baby died from hyperkalemia. :wow:

I was skeptical, because wouldn't the baby have refused it because it tasted bad? OTOH, apparently a newborn's taste buds aren't very well developed.
Holy cow.
How??? Don't they have giant letters saying "CONCENTRATED DIALYSIS SOLUTION" or something?
How did the kid not vomit immediately?
Scary.

Everyone in Texas has heard the story of the RPh who sold someone a bottle of automotive glass filler instead of mag citrate.
 
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BidingMyTime

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This one happened to me personally, I had a script for penicillin and received pentoxifylline. Since I was a pharmacist at the time, I realized the error and immediately took it back. I was pretty annoyed, because I was sooooo sick, but it happens. This was back when computers were fairly new, I didn't work at the pharmacy I got my RX filled at, but I guessed their system had some kind of auto-fill in or drop down.

Other potentially bad errors I've seen weekly medicines put in as daily. Thankfully, very thankfully, I've never seen a major error that permanently harmed someone.
 
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PolarPop

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Not really a terrible mistake but I remember when I was an intern one of the IPPE students gave a flu shot and left the needle in the patient. He just stood there in shock not knowing what to do and then finally pulled the hub out with his hand. The lady didn't even realize it.
 
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Old Timer

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A pharmacist sold dialysate instead of distilled water to a parent, for mixing baby formula. The baby died from hyperkalemia. :wow:

I was skeptical, because wouldn't the baby have refused it because it tasted bad? OTOH, apparently a newborn's taste buds aren't very well developed.
I don't believe this for a second. How does this happen? They sell this stiff by the gallon? It's not otc. This looks to be urban legend.....
 

rph3664

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I don't believe this for a second. How does this happen? They sell this stiff by the gallon? It's not otc. This looks to be urban legend.....
I've also never seen dialysate in any pharmacy, retail or hospital, but the pharmacist who told me about it was quite reliable (and no, he wasn't the one who did it).

Not quite retail, but at the mail order place I worked at as a student and then for a couple years after graduation, before they became automated, a patient called customer service to say that their Pepcid tablets were filled with some round tablets that had the word c-o-u-m-a-d-i-n on them. :eek: Obviously, this was back when Pepcid was RX and brand only. That, I find far more believable.
 

radio frequency

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The "methotrexate subbed for fluoride numerous times" incident in Jersey has to be up there. It's the reason we have those stupid blue dustpans we have to pour every script through at CVS.
Was it methotrexate actually or is this a separate incident with the tamoxifen subbed for fluoride? Yikes! I always check the small numbering and lettering and these incidents make me glad I do. Chatham CVS gives children breast cancer medication in accidental pill mix-up
 

Old Timer

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Was it methotrexate actually or is this a separate incident with the tamoxifen subbed for fluoride? Yikes! I always check the small numbering and lettering and these incidents make me glad I do. Chatham CVS gives children breast cancer medication in accidental pill mix-up
No, it was not methotrexate, it was Tamoxifen. It was done by a moron who did not follow procedure when doing rts and labeled a bottle of Tamoxifen with an RTS label for NaF and then placed the Tamoxifen in the Script Pro, thinking it was NaF.
 

radio frequency

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No, it was not methotrexate, it was Tamoxifen. It was done by a moron who did not follow procedure when doing rts and labeled a bottle of Tamoxifen with an RTS label for NaF and then placed the Tamoxifen in the Script Pro, thinking it was NaF.
I've seen similar mistakes happen elsewhere. I've caught this a few time myself (a mixup between two CIIIs). I also saw something similar happen with some CIIs. So glad I wasn't involved in that...
 

Digsbe

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I knew a tech who sold someone the wrong bag, it was filled with oxycodone for someone else. When I was a tech (luckily not involved) respiridone and ropinirole got mixed up, sent the patient to the ER.
 

maria1oh

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The blue visual verification trays were actually born in ohio due to the state Board investigation of patient death after receiving a bottle labeled for carbamazepine that actually had prednisone tablets.

The jersey incident only required script pro stores to do the full pour verification but after the ohio incident every store in ohio had to do it.
 
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WVUPharm2007

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WVUPharm2007

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sosoo

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The fact that you admit it and don't care is what's concerning.
no. the fact is im gathering info so hopefully i can someday file a lawsuit.
 

Carboxide

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RPh dispensed trazodone 100mg TID instead of tramadol to a 90yo pt. Had MVA.
 
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sosoo

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You need to consult a lawyer if this is true. Your methods seem flawed.
i went through a whistleblower law firm already, but to file a false claims act and collect money i needed to provide more concrete evidence. it wasnt possible so it was dropped. now i could bring this to the news channel but theres no money to be made there. so im still waiting to see what i can do with it in the future.
 

CetiAlphaFive

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i went through a whistleblower law firm already, but to file a false claims act and collect money i needed to provide more concrete evidence. it wasnt possible so it was dropped. now i could bring this to the news channel but theres no money to be made there. so im still waiting to see what i can do with it in the future.
Wow.
Just wow.

Here's your original post on this subject:

Medication expiration

You clearly stated and believed that moving pills from a stock bottle to Rx bottle changed the expiration date of the med.
Now you're changing your story to save face.

You have absolutely ZERO credibility.

I guess I'll add #5 to my post from the thread where you originally started this craziness.

That's a contradiction.

You've stated three mutually exclusive things in this thread:
1.) The pharmacist never sees the bottle.
2.) The pharmacist sees it but there's no way to change it.
3.) It's a company wide problem that no one can fix.
EDIT: 4.) you originally stated that changing bottle extends the expiry date.
I used to do it all the time at my CVS.
Back when I was an RPh there, it was under "Additional info" in the production screen.
Not hard.
5.) You've apparently magically changed your mind since July 21st and met with lawyers, who then decided to drop your "case"
 
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sosoo

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Wow.
Just wow.

Here's your original post on this subject:

Medication expiration

You clearly stated and believed that moving pills from a stock bottle to Rx bottle changed the expiration date of the med.
Now you're changing your story to save face.

You have absolutely ZERO credibility.

I guess I'll add #5 to my post from the thread where you originally started this craziness.



5.) You've apparently magically changed your mind since July 21st and met with lawyers, who then decided to drop your "case"

dont be stupid. the whistleblower lawyer was all throughout 2016. it was dropped long ago thats why im ok mentioning it over the web..... also, its obvious im not telling the full story.
 

CetiAlphaFive

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dont be stupid. the whistleblower lawyer was all throughout 2016. it was dropped long ago thats why im ok mentioning it over the web..... also, its obvious im not telling the full story.
I'm sure you haven't fabricated the full story yet.

I'll be fascinated to see where you take it from here.
 

Rouelle

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i went through a whistleblower law firm already, but to file a false claims act and collect money i needed to provide more concrete evidence. it wasnt possible so it was dropped. now i could bring this to the news channel but theres no money to be made there. so im still waiting to see what i can do with it in the future.
Wait...you're trying to collect money by selling out your employer? Have you been personally wronged in some way by the expired med issue?
 

owlegrad

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Wait...you're trying to collect money by selling out your employer? Have you been personally wronged in some way by the expired med issue?
Isn't that how all whistle-blower cases go? Why sell out your employer if you aren't going to profit from it?
 

sosoo

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Wait...you're trying to collect money by selling out your employer? Have you been personally wronged in some way by the expired med issue?
most cvs pharmacists have been wronged one way or another. 24-hr pharmacists for example worked like a slave without proper staffing. working 1-2 hours extra after shifts to complete tasks otherwise get yell at or fired by the supervisor. its part of a modern day slavery system. lets not even mention the people who come on their day off to work for free. at least that is how i see it with cvs pharmacies. now if you remember people picking cottons, u know how that turn out.
 

trailerpark

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People at CVS come in on their days off? To do what? I could see paperwork or manager stuff, but to fill prescriptions, srly?
 
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CetiAlphaFive

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most cvs pharmacists have been wronged one way or another. 24-hr pharmacists for example worked like a slave without proper staffing. working 1-2 hours extra after shifts to complete tasks otherwise get yell at or fired by the supervisor. its part of a modern day slavery system. lets not even mention the people who come on their day off to work for free. at least that is how i see it with cvs pharmacies. now if you remember people picking cottons, u know how that turn out.
Pffffft, 24 hour pharmacists have the cushiest job in all of CVS.
7 on, 7 off basically translates to 6 extra weeks of vacation per year.

And, outside of the barrio/ghetto areas, they're not that busy during the "graveyard" shift for an experienced pharmacist.


P.S.
It is extremely offensive for an asian/white person living in modern day America to compare their 6 figure, air conditioned job to plantation era African American slavery.

It's like someone with a sprained ankle walking into the burn Ward and saying, "man, we have got it really bad, huh?" to someone with 75% of their body burned.

Just an FYI so you don't commit such an embarrassing faux pas in real life.
 

quickpic007

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Pffffft, 24 hour pharmacists have the cushiest job in all of CVS.
7 on, 7 off basically translates to 6 extra weeks of vacation per year.

And, outside of the barrio/ghetto areas, they're not that busy during the "graveyard" shift for an experienced pharmacist.


P.S.
It is extremely offensive for an asian/white person living in modern day America to compare their 6 figure, air conditioned job to plantation era African American slavery.

It's like someone with a sprained ankle walking into the burn Ward and saying, "man, we have got it really bad, huh?" to someone with 75% of their body burned.

Just an FYI so you don't commit such an embarrassing faux pas in real life.
ehhhhh

I'd say staff spot at low volume cvs is easier than graves at 24 h cvs....
then again my 24 cvs was in a ghetto area

biggest mistake i heard:
rph stuck them self with imz needle
 
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sosoo

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Pffffft, 24 hour pharmacists have the cushiest job in all of CVS.
7 on, 7 off basically translates to 6 extra weeks of vacation per year.

And, outside of the barrio/ghetto areas, they're not that busy during the "graveyard" shift for an experienced pharmacist.


P.S.
It is extremely offensive for an asian/white person living in modern day America to compare their 6 figure, air conditioned job to plantation era African American slavery.

It's like someone with a sprained ankle walking into the burn Ward and saying, "man, we have got it really bad, huh?" to someone with 75% of their body burned.

Just an FYI so you don't commit such an embarrassing faux pas in real life.
im thinking of the ppl i observed coming in on their day off to work "modern" day slave hours. the daytime staffs. and the terrible work condition that they are in. i haven't seen any overnight pharmacists or did i mention any. did i? ... now i can't imagine who would be offended by white/asian mentioning the issue of modern day slavery. slavery of qny kind should be reported and bring to light. u dont have to pick cottons to know the pain. (in case your history lessons suck, asian were slaves and got it worst). remember the chinese eunuch who got their testicles removed? prior to starting a lifetime of slavery?
 

CetiAlphaFive

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im thinking of the ppl i observed coming in on their day off to work "modern" day slave hours. the daytime staffs. and the terrible work condition that they are in. i haven't seen any overnight pharmacists or did i mention any. did i? ... now i can't imagine who would be offended by white/asian mentioning the issue of modern day slavery. slavery of qny kind should be reported and bring to light. u dont have to pick cottons to know the pain. (in case your history lessons suck, asian were slaves and got it worst). remember the chinese eunuch who got their testicles removed? prior to starting a lifetime of slavery?
You literally did mention overnight.

It's right there.
 
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Rouelle

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most cvs pharmacists have been wronged one way or another. 24-hr pharmacists for example worked like a slave without proper staffing. working 1-2 hours extra after shifts to complete tasks otherwise get yell at or fired by the supervisor. its part of a modern day slavery system. lets not even mention the people who come on their day off to work for free. at least that is how i see it with cvs pharmacies. now if you remember people picking cottons, u know how that turn out.
Most employees of any employer have been wronged in some way or other. That's life. If you can accept it, stay with the company. If you cannot, quit. If you're concerned about practices that affect patient safety, call the company ethics line or your state BOP. If you're simply trying to rat out your company for financial gain just because you had to stay late or go to an unpaid meeting, then that behavior is disappointing.
 

Winged Scapula

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im thinking of the ppl i observed coming in on their day off to work "modern" day slave hours. the daytime staffs. and the terrible work condition that they are in. i haven't seen any overnight pharmacists or did i mention any. did i? ... now i can't imagine who would be offended by white/asian mentioning the issue of modern day slavery. slavery of qny kind should be reported and bring to light. u dont have to pick cottons to know the pain. (in case your history lessons suck, asian were slaves and got it worst). remember the chinese eunuch who got their testicles removed? prior to starting a lifetime of slavery?
Actually comparing working a white color job *of your choosing*( in a first world country which requires a higher level of education than most people in the world have) to slavery is offensive to those who have had ancestors who were slaves.

Regardless of their (slaves) ethnic identity, this is offensive.
 

sosoo

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Most employees of any employer have been wronged in some way or other. That's life. If you can accept it, stay with the company. If you cannot, quit. If you're concerned about practices that affect patient safety, call the company ethics line or your state BOP. If you're simply trying to rat out your company for financial gain just because you had to stay late or go to an unpaid meeting, then that behavior is disappointing.
u must have been in a dark cave somewhere. with the Wells Fargo scandal, the employees brought their concerns to ethics hotline and got fired.. they brought complaints to department of labor and got ignored.. the board will also do the same. please don't give terrible advise.
 

sosoo

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Actually comparing working a white color job *of your choosing*( in a first world country which requires a higher level of education than most people in the world have) to slavery is offensive to those who have had ancestors who were slaves.

Regardless of their (slaves) ethnic identity, this is offensive.
thanks for defending those who feel offended. and i apologize to those who feel offended. this includes white ppl who's ancestors who were also slaves. asians, indians, blacks, u name it.. im just surprise you're all ok with "modern day" slavery.
 
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