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Pharmacy Error -- here's a story for you all.

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Posted 4/14/2012 10:20 PM (GMT 0)
Hi All,

I discovered something today. I was filling my weekly pill organizer and emptied my bottle of Tramadol ER onto my bed. Usually, I just pluck individual pills from it, but this time, emptied it out.

To my astonishment, the bottle had pills of two different sizes and imprints. Some were PAR 822, some PAR 823. So, I realized that the pharmacy (a CVS) must have mixed the two together. Of the 40 or so remaining in the bottle, about half were of one type, half were of the other: Tramadol ER 200mg vs. Tramadol ER 300mg.

This might also explain why I've been in more pain than usual since February!

So, I phoned CVS, talked to a pharmacist and then went over there. They replaced the incorrect pills and I noted that the script cost about $600 for 90 days. Thus, I should be reimbursed for the mistake. The pharmacist said he will talk to the manager on Monday.

My wife actually wants me to contact an attorney and sue them for the extra pain, but that seems overkill. I did though take pictures of the bottle and its contents and will report them to CVS corporate as well as the state pharmacy board.
Posted 4/14/2012 10:43 PM (GMT 0)
Pharmacists are human....they make mistakes just like the rest of us....Thankfully it wasn't anything that could have harmed you...

I certainly wouldn't sue..

It's definitely a lesson to ALWAYS check our medication when we get home...(Some even do this at the Pharmacy)....

To not only count our meds...but look and make sure they are the correct ones...

Appreciate you sharing your story as it is a great reminder to us all...I'm sure they will credit you your money as that is only fair....
Posted 4/14/2012 11:52 PM (GMT 0)
Wow.

I would be angry about this... luckily, your "only" thing was more pain... having 2 different meds is unacceptable and, to me, beyond a human mistake. A human error would be having one too many pills or being short a pill.

I personally wouldn't sue but would do as you said and contact corporate, etc.

...Tina
Posted 4/15/2012 12:10 AM (GMT 0)
They aren't even supposed to mix two different batches of the same med in the same bottle.
That's a pretty big error.
Posted 4/15/2012 1:49 AM (GMT 0)
Good reminder to check our meds before taking them...either at the pharmacy or at home.

I am glad that you are not going to sue. I think it would do more harm than good and I also think it would be a very difficult case to win as you would have to determine who was really at fault and also since it was a matter of a different dose of the same med rather than getting the wrong med it would be very difficult to quantify things as far as pain goes and being able to prove that the dose issue caused the majority of the increased pain rather than having a pain flair up.

Besides that a big chunk of the reason medical costs are so high is because people are too quick to sue any more and when juries do side with the plaintiff they are too quick to award ridiculous settlements. In the end these settlements do little to hurt the companies as they just end up passing on the amount to their customers.
Posted 4/15/2012 2:40 AM (GMT 0)
I had a problem with CVS a couple of months ago...picked up my prescription for Baclofen which was supposed to be 90 pills but there were only 60. I noticed this a couple of days after filling it and called the pharmacy & they said to bring the bottle in and they would give me the remaining 30...Won't give you the whole story, but they did not do that when I got there. They kept telling me that two people had initialed that the quantity had been checked and I kept telling them that they can say that all they won't but that it doesn't prove that two people actually counted. I ended up calling the district manager and she straightened it out immediately and I was able to get the remaining 30. Ever since then the minute I get in my car I check all the bottles & quantities...I sometimes will check them while I am still in the store, but only if there aren't other people waiting. I realize that everyone makes mistakes, but making mistakes with medications is really bad. Good luck with contacting CVS corporate!
Posted 4/15/2012 3:26 AM (GMT 0)
I found a state pharmacy board complaint form and depending upon what the manager says to me on Monday, I'll fill it out.

I was looking at the previous bottle of my Tramadol ER and I realized that they could not possibly have fit 90 300mg pills into it. It was too small.

So, I at least know when the error happened and which pharmacist was responsible. Since the makers of the generic ship it in bottles of 30, I'm now suspecting that the pharmacist pulled one or two of the wrong strength. He may not have counted them out since he was just opening sealed bottles.

Anyhow, this should just not happen -- and it seems to be happening a lot at my local CVS. Imagine if this was a more dangerous drug and the pharmacist pulled a dose too high which lead to respiratory depression and death. That just as well could have happened. What if, for instance, I was taking 10mg oxycontin and he accidentally pulled an 80mg bottle?

I also wonder, as I look back at the past few months, how much of my additional pain was due to this error. I now have 15 oxycodones left, which I use only when the pain is at its worst. I don't see my PM until June and will have to make them last until then. Though I could tell my PM this story and ask for my oxycodones early, I'm just too uncomfortable doing so, especially since this will also be the first time I have to ask for a hydrocodone refill before my appointment (since he insisted that I take 2-3 per day -- again, because of the increased pain).

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Posted 4/15/2012 4:38 AM (GMT 0)
I just had a problem with two of my medications and my pharmacy this month as well. My baclofen and my tizanadine ( xanaflex) are both very similar in shape and size , however one has a little lip to the edge of the football shape on the tablet and the other doesn't. Anyway, when I picked up my meds this month, I got home and quickly opened the bottles , just for a visual check to make sure they appeared to be right.......anyway both the baclofen and xanaflex looked exactly the same......I thought at first that I was mistaken and had accidentally opened the same bottle twice, but that wasn't the problem. I called my pharmacist and explained to him what I was seeing, and we both checked the imprints on both meds- sure enough, someone had accidentally filled both bottles with xanaflex, instead of one being filled with baclofen. Thankfully, I always do that quick visual check to make sure that all of my meds are right, but it could have been a horrible month for me, while taking too much ( a double dose) of xanaflex and sudden withdrawal of baclofen, which can cause baclofen withdrawal syndrome if I hadn't....

Anyway, just a reminder to make sure to either count or check that your meds look as they always do, and to confirm that they are in fact the correct medication, in the right bottles , for your own safety. No matter whether you use a mom and pop pharmacy or a retail chain store......anyone can make mistakes.

 

Posted 4/15/2012 11:39 AM (GMT 0)
Hello everyone
I work at a small pharmacy
The best thing I feel you could do is before you leave check your bottles
if anything looks different your in the store and can show them and ask ?
Techs count meds, Pharmist is suppose to open the bottle check to make sure what is in
Is correct .I think they have become so big wanting to get scripts out quickly they may over look
We had a pharmist like that he came in 2 day a week for our pharmist he never checked to see that it was correct
They let him go, And I know we dont do near the business that a big pharmacy will do,
Its easier to catch it there ,Better to take an extra step
Have a great day
Renee
Posted 4/15/2012 1:56 PM (GMT 0)
Just wanted to say that even though I don't think you should sue....I definitely agree with contacting corporate and filling out a complain form so that they are aware of errors....

So...I should have stated that in my post...that it's important for the company to know who is making errors and how many times (based on complaints)...

Keep us posted..
Posted 4/15/2012 4:34 PM (GMT 0)
CVS had a big news story last year, as they were selling old medicines and expired medicines...
I don't think you should ever do business with CVS again and ask your pm doctor at the
next visit if you can switch to a different pharmacy because of this error...and make
sure to get your monies back...just my 2 cents worth of advise and I'm sorry this
happened to you and hope you get low pain days, soon...and do file a corporate complaint...

Could be that this pharmacy had too much of the one medicine and didn't think you'd notice
the differences...sad to say....but it was still wrong for them to do....
Posted 4/15/2012 5:05 PM (GMT 0)
Here is something for everyone to chew on. My husband was using a brand name medication and when it was refilled for whatever reason it was filled with the generic brand. He had no clue about this until he got home and opened the bottle up. He called the pharmacy and told them what they had done and they refused to take the medication back. He just wanted to give the generic back and get brand name. They said it was against the law for them to accept a returned medication once the person left the store with it. We have used this pharmacy for 20 years and they know us very well. I called different pharmacy and sure enough was told the same thing. After that, we learned to go over and sit down in one of the chairs at the pharmacy and take our meds out and make sure they are the correct ones and if we think we have been shorted we ask for a recount. It was not our normal pharmacist that did this either.

Bottom line is everyone needs to take the time before leaving the store and make sure your meds are ok.....Susie
Posted 4/15/2012 5:32 PM (GMT 0)
Thanks for the ideas.

I can't see myself sitting down and checking the scripts right there -- given all the opioids & benzos I get, it would look fishy. But I might go to my car and check them.

Also, I do think I should find a new pharmacy. Any suggestions? In addition to CVS we have Walgreens here. Does anyone use Walgreens? I just don't like their "feel", but have no clear, rational basis.

I'll also look into private pharmacies, but I can't think of any located near my house. The nearest hospital is about 4 miles from here and I know there is one across the street. That is I think the closest.
Posted 4/15/2012 6:42 PM (GMT 0)
Hey Cogito,

Yeah, I'm the same - I get too many meds to sit and look them over at the pharmacy. I only look at them to see if they look to be correct bottle size/amount - once I get home.

I only use Walgreen's. Overall, I've been very pleased. But, I mainly go there - but not because it's Walgreen's - but the pharmacists and staff know me and treat me well.

Good luck.
--Tina
Posted 4/15/2012 10:19 PM (GMT 0)
I went to three pharmacies today: a Walmart Supercenter, a Walmart Neighborhood Narket and a Walgreens. When I told their pharmacists about what happened at CVS, they all mentioned that they've received a lot of transfers from that location. The staff at all three locations were very nice and went through the prices of all 10 meds I take.

Here are the quoted prices for Tramadol ER 300mg (30 pills), my most expensive medication:

Walmart Supercenter = $143
Walmart Neighborhood Market = $285
Walgreens = $220 (they have a discount card that brought it down to $190).

CVS charged about $200.

The pharmacist at the Neighborhood market was astonished by the difference. They use a Lupine generic whereas I've been taking one made by Par. The guess is that the Supercenter must be using a cheaper generic.

Aside from that, other prices were relatively similar. I started 25mg Lyrica a few days ago and it ranged from $175 to $225 for 60 pills.... BTW, the Lyrica really helps with the pain but makes me feel lousy. I don't think I'll be able to take it daily as I won't be able to write given its impact, but may use it during pain flares.

I'm eager to see what the CVS manager has to say tomorrow. If he doesn't call me, I plan on going there to talk to him. Tomorrow, I'm going to check out a few individually owned pharmacies as well.
Posted 4/15/2012 10:44 PM (GMT 0)
I take lots of meds too but do not have them filled at the same time. With the law being as it is my state I have no choice but to check my meds before leaving the pharmacy. I get the same meds filled every month so I know pretty much how full the bottles should be and no one has a clue what I have in those bottles. Our pharmacies have even changed up how you pick up your scripts when they are ready for pick up. Only one person is allowed at the counter and waiting customers stand back a good five feet from the counter which I like that idea, because it does allow for some privacy. Just be sure you know your state laws concerning pharmacies, we found out the hard way.

CVS has a bad reputation where I live. I use a pharmacy located in my grocery store, but have used Walgreens if my store does not have my meds.

I would report the store to the district manager they need to be aware of this. Good luck.
Posted 4/15/2012 11:41 PM (GMT 0)
I use a Sam's club Pharmacy....By law you do NOT have to be a club member to use Pharmacies of big box stores...

I have called around to just to check...and they are the absolute cheapest of all the Pharmacies in my area..

I get 5 different prescriptions...all generic...and it costs me $135 per month...That is pretty darn good for five different medications!...

The key is finding not just the best price but also finding a Pharmacist that can really be a part of your medical team. I've know my guy for over 11 years. I make sure we always chat when I go there. He knows all about every medical condition I have...So if there has been any type of glitch...he would bend over backwards to solve the issue.

I hope you can find a place that you really like!!
Posted 4/15/2012 11:46 PM (GMT 0)
I am with Tina....I would not sue but would definetly report this...it could have been worse!
Posted 4/16/2012 12:16 AM (GMT 0)
Hi cogito I'm sorry this happened to you. I would definitely report the pharmacist to the appropriate person. We use Rite-Aid and haven't had any problems with them. We also have used Walgreens in the past and they were good too.

I wish you good luck in finding a good pharmacy.

hugs
Loretta
Posted 4/16/2012 12:21 PM (GMT 0)
I would also report... but I'm amazed by this for other reasons too - I never realised when you guys mention medication bottles that your scripts are made up like that. Do your tablets not come in boxes or blister packs? Something like my Oxycontin for example - comes in a blister pack, in a cardboard box with a tamper-proof seal, and 'consumer information' leaflet in the box. Unless it's something specially compounded, or a really unusual med - all our scripts come like this or in sealed bottles.

Laura
Posted 4/16/2012 3:43 PM (GMT 0)
Laura,

I think it's so interesting to hear how things are done in different places.

Most meds here come in medication bottles. You bring your script into the pharmacy and the pharmacist puts that quantity of meds from their stock (which is usually a bigger said medicine bottle) - into the bottles you take home.

Many "over the counter" meds we buy here (like cold medication and so forth) - come in the blister packs w/ a tamper-proof seal.

:) --Tina
Posted 4/16/2012 3:45 PM (GMT 0)
Cogito,

I was hoping the Lyrica would work for you.... I'm sorry it had side effects for you :(

--Tina
Posted 4/16/2012 4:42 PM (GMT 0)
Costco is another place to check I have heard they are cheaper than anyone and you do not have to be a member.
Posted 4/16/2012 5:06 PM (GMT 0)
I agree with straydog if you have a Costco check it out here it is the least expensive. I get my meds from a Safeway pharmacy and the pharmacist always opens the lids on all bottles so we can both see and if I never have had a certain drug before he makes sure I understand what it is. I recently had a different generic oxycodone and the phamacist told me it was a different company and they use a different filler so if I had any troubles we would be aware, the only thing different that I can tell is it dissolves almost instantly in my mouth and of course due to that I think they do not work as well.
Posted 4/16/2012 5:30 PM (GMT 0)
Unfortunately there's no Costco around here. There is a Sam's club but it is not convenient for me. If I feel up to it, I'm going to visit some smaller pharmacies around.... and I'm still waiting to hear from CVS.

CRPSpatient, as others have mentioned, I usually receive my meds in pill bottles filled from the pharmacy stock. Sometimes I get sealed bottles from the manufacturer, such as when I have a script for 90 and the bottle is shipped to the store has 90 pills. But most of the time, it is in a CVS pill bottle.
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