CVS and Prescription Mix Up

[Bananamama]

I went to CVS this afternoon to pick up Ali's Pepcid. Our neighbor was working the drive-thru, so we got to chatting a bit before I took Ali's prescription and left. Whenever I use the drive-thru, I always, always, always pull ahead to check the prescriptions before leaving the parking lot. Today I didn't, and wouldn't you know we got the wrong prescription.

We got home and I did check the label before drawing it up into a syringe. First thing I noticed was the dose was off. I thought that was funny, because when Dr. R. and I talked last week, she mentioned that Ali's dose could not be increased at this time. So I looked closer, and that's when I realized it wasn't even Ali's prescription!

I called CVS, and they told me I had to bring it back in. After talking with my mom, she thinks I should contact the corporate offices because this has been all over the news as happening with CVS a lot around here. Of course, the problem is that it was our neighbor who gave us the wrong script. Now it's not like we're friends or even friendly. She didn't even recognize me the first 1/2 dozen or so times I went in there. But it would still be awkward. Then again, we're moving the end of the month. So what would you do? Make a stink or think no harm, no foul?

Part of me thinks I should let it go, but then the other part of me thinks it's a pretty big deal. What if it was a new med and I didn't know what it was supposed to look like? What if I didn't even check? What if it was a heavy duty drug in an adult dose and I gave it to my baby?

What would you all do?

Thanks,
Kelly

[ajtroisi]

If it were me, I'd go by how the pharmacist and staff act about it. If they treat it like a huge deal, "We're so sorry....etc" I'd be more inclined to let it go. BUT, if they respond like it's no big deal, I'd go higher. I was a pharm tech for 13 years and while these things did happen (rarely), we always scrambled big time to apologize, make it right, etc. We'd deliver the right med, so as not to incovenience the already ticked off patient.

Glad you caught it in time.

[jularias]

You could see how they react. A couple of years ago I had a big issue with Max's compounded prilosec-the pharmacy gave me a three month's supply-ok, it only last 30 days??? (the HMO pharmacy nearest me always did 30 days and said not to keep it any longer) Whan I said, no thanks-it only lasts thirty days I only want a 30 day supply-they complained saying they were saving me money-Ugh! I left pretty upset-I told them it does not save me money if Max aspirates the reflux and ends up in the hospital with pneumonia b/c the medicine is outdated. Moreover, I later found even with 30 days-they had made the stuff 10 days before. I did a lot of checking with the company, our local children's hospital twice-our HMO pharmacist refused to call them, and a very nice pharmacist a sav-on even called the company for me. I couldn't find anywhere that said 90 days was ok so I did contact our state pharmacy board and the HMO pharmacy administration. I cited the published research-I don't think they knew I was just a mom. They called me back! In the end our HMO agreed to make only 30 days at a time- (for everyone) they still claim 90 is fine but....

If it's happening a lot the state pharmacy board might be the one to contact. Ours had a web site with the information they needed listed. One thing they wanted was the original container. I figured they were the ones who would know how big of deal it was and what to do.

My personal feeling is that if medicine was labeled with someone else's name most people would notice. If it's a one-time thing, I wouldn't think the phramacy board or CVS administration would make a big deal out of it. But if you let them know and they have several complaints about the same pharmacy or the same person they might do something. You can be nice-just state what happened and why you were concernced.

Julie

[Bananamama]

Thanks for your responses

Even when I called them yesterday to let them know, they were very casual about it. And it's not even really that I'm all that upset. It was a medication that she can live without for a day or two, so we weren't inconvenienced in that sense. And, I did catch the error before I gave it to her. Not to mention, part of me feels responsible for not checking before I left the parking lot, which I always do.

Jennifer - Granted I haven't yet spoken to anyone in person, this wasn't the response I got on the phone. I was simply told, "You have to bring that back, okay?" I said, "Okay," and that was it. Literally. The weird thing is she is my neighbor and the medication has to be constituted with water at pick up, so you think she would have looked at it and realized it wasn't right. But again, no harm, no foul.

Julie - Holy moly, I can't believe you had to convince them that a 90 day supply of a compounded ppi is not a good idea! What is up with that?! Good for you for following through with it, and thanks for letting me know about the state pharmacy board. I wasn't aware there was such a thing.

I would just hate to see this happen to someone who might be less inclined to check the label and with a medication that could have more serious effects if taken by an infant. I live in an area that is largely populated by uneducated people (and no, I'm not making a generalization), so it's not out of the realm of possibilities.

Thanks again for your responses!
__________________

[Hannamom]

Considering how many times CVS has done this...I would say something...Just another reason why I left there and now go to Brooks.

I think it is a serious problem that CVS has, and if it was not you picking the med up, and looking at it, it could have been some old person or new mom who does not think to look...and who know what would of happened.

I would call the news channel "Help me Hank" ..screw the cooprate CVS offices...remember they don't want people to know this. Do you know what kind of med it was by chance?

[Caleb's mom]

I would NOT just sit back!!!!!! I don't think CVS can handle the load since they bought out Eckerd a while back. I use my local grocery store now for all prescriptions except Caleb's compound prescription. They know me by name b/c they are small and they have never messed anything up. They even told me that a generic would be in the following day for a medicine I was going to pick up. It was a new generic. They saved me $30.00 by telling me to wait one more day.

I would be all over CVS and go to your local new station as well. News people love that kind of stuff. Sorry that it is your neighbor, but a child could have been given the wrong medicine.

Lorie

[ronnor926]

As a pharmacist, here is what I think.....

You need to speak to the manager of the pharmacy and then take it from there. It has happened at my store and it will happen again but we do have safe guards. We are all trained to verify the patients address and dob at the out window to make sure we are giving the right medication to the right patient. But sometimes either the techs know the person and don't think it is necessary or they just don't do it if there is a line or what. I would ask the manager what steps they have in place to prevent this from happening.

It is crazy to me that I can be as careful as I can to fill the prescription correctly and then in 1 careless minute a patient can get the wrong medication. BUT that is the way pharmacy is...scary isn't it????

I can only applaud you for actually reading the label.....you would be surprised the number of people who don't even read their labels....one gu just came in my last day and said he only takes his med once a day even though his label says 2 per day...and his doctor couldn't understand why his blood pressure was still high and was adding another drug.......

As crazy as it is....check every label everytime. I did is with all of the boys meds in the hospital. Errors happen but I did not want one to happen to my kid!!!

[Bananamama]

UPDATE: Well, I went to CVS and spoke with the head pharmacist. I did stay very calm, though I still wanted to leave an impression. I explained that while I was upset, we were all fortunate that the error was caught before I gave her the medication. What I didn't understand was how someone could take the box(with this other person's name on it) with the Pepcid bottle in it out of the bag (which had my daughter's name on it), and then take the bottle out of the box (also with this other person's name on it) to add the water, put the bottle back in the box, the box in the bag, ring it up, give it to me, and never notice that the names/addresses didn't match. He agreed that it was unacceptable and was very apologetic. I told him that's all well and good, and I appreciate his apology, but it doesn't change the fact that I was given a prescription for twice the maximum dose for my daughter's weight. The way we left it was that their store would hear from me in writing by the end of the week and that I was also contacting the CVS corporate offices and the state board. And, I'm transferring our prescriptions to a small, independently owned pharmacy in the town where we are moving to.

So you want to hear the kicker? The woman behind me was there for the exact same thing! She had been given a medication for controlling blood sugar instead of blood pressure.

Amy - First of all, congratulations on your newest addition! She is beautiful! Thank you for weighing in on this. I agree that mistakes can happen, which is why I always (though now I have to say almost always) check my prescriptions before leaving the parking lot. And even when I give the girls their medications, I check each and every time to make sure I'm giving each girl the correct med at the correct dose. The only reason I decided to take this above and beyond, is it seems like CVS is having a huge problem with such errors.

Lorie - I didn't realize that CVS bought out Eckerd. We'll be switching to a small, independently owned pharmacy once we move. It's hard because CVS has a drive-thru, which is so convenient with a couple of kids. I'll trade safety for convenience, though, any day!

Christine - I didn't realize how much this has happened with CVS until reading your post. Then I googled it, and they are really in some hot water. Is "Help Me Hank" Hank Phillippi Ryan? I miss the Boston news channels! Soon... The medication was Pepcid, so it wouldn't have been the end of the world had I given it to her. Dr. R. has been adament, though, that her dose cannot be increased at all, so I don't what effect it would have had to give her twice the maximum amount. Probably nothing if it was only a one time thing, but still...

Thanks again for all your responses!

[ronnor926]

I think you are doing the right thing. The corporate office must be made aware that this is such a problem in their store. They can easily push incidences lke this under the rug to protect thier people. It may turn out to be the smae employee every time.....

When Ryan and Connor were in the NICU, a nurse gave Ryan Connor's dose of caffeine. There was quite a difference in weight so the dose was quite different. I handled it by talking to the attending, nurse manager, and then talking to the nurse who made the error. I told her I know mistakes happen but she needs to be thankful that the mistake she made was not a critical one and to learn from her mistake.

Let us know what CVS says.......I am interested to know if they will address you personally or handle it by a standard error letter with compensation like a gift card or something..........

[ChillyJJ]

I had M's trazodone rx filled last week and when I picked it up the pharm said, 1/4 tablet once a day and I freaked! Our initial rx was for 25 mg, and we were given 50 mg tablets, so he had been taken a half tablet. We did not see the dr for his rx renewal, saw a student (I assume it's a student) who wrote the rx and had the dr sign it... but I didn't look at the rx when I got it so didn't realise she has written it for 100 mg tablets instead of the 50 mgs ones. But our pharm here shows you the meds, goes over the dose, and it's the pharmicist that gives you the rx before you check out.

Mistakes happen, but if they are a continuing problem with CVS, then they need to look into their proceedures and training programs and an overhaul of how things are done might be in order.