Viewpoint: Memorable misfills of a retail pharmacist - Memorable misfills of a retail pharmacist

Viewpoint: Memorable misfills of a retail pharmacist - Memorable misfills of a retail pharmacist - ModernMedicine

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1. Mepergan Fortis/cephalexin: A pharmacist told me this story. She discovered that she had dispensed Mepergan Fortis (meperidine/promethazine, Wyeth) (a powerful narcotic pain reliever) instead of cephalexin 500 mg (an antibiotic). It's easy to see how this error occurred. Both are dark red capsules. She called her husband and told him to go to the customer's house to retrieve the Mepergan Fortis. She cried into the phone to her husband: "GO GET IT! GO GET IT!" Her voice broke as she told me the story.

Dennis Miller, R.Ph.

2. Prednisone/phenobarbital: Another R.Ph. told me he once worked for a large chain in a state that requires a pharmacist to be on duty at all times if there is no way to adequately secure the pharmacy from access by the public. One morning he discovered he had mistakenly dispensed the steroid prednisone instead of the antiseizure drug phenobarbital. He told me he was so worried that he locked the doors for the entire store and drove to the customer's house to retrieve the improperly filled Rx.

3. Coumadin/Cardura: One tech in our pharmacy put the blood thinner Coumadin (warfarin, Bristol-Myers Squibb) 4 mg in a refill bottle for Cardura (doxazosin, Pfizer) 4 mg (used for enlarged prostate or hypertension). I told her that Coumadin is probably the most dangerous drug in the pharmacy, and that I had just prevented her from killing someone. I made a joke out of it because I didn't want her to lose confidence in her abilities or to dislike working with me. She told me she needed to slow down. I said, "No. You need to continue at the same speed. If you slow down, we'll get completely covered with prescriptions. It's my job to catch your mistakes."

4. Glucophage/Toprol XL: I was visiting my stepfather when he opened an Rx bottle and asked me why half the pills looked different from his usual pills. I had that sinking feeling we pharmacists experience all too often: another misfill. A major chain had mixed Glucophage (metformin, Bristol-Myers Squibb) for diabetes with my stepfather's Toprol XL (metoprolol, AstraZeneca), for blood pressure. He has never had diabetes.

5. Carbamazepine/theophylline: A local doctor told me that one of his patients was in his office "and he's dying." The doctor proceeded to tell me that we had dispensed carbamazepine (which treats seizures) rather than theophylline (which treats asthma). We had dispensed the drugs in the manufacturer's original container, so the doctor knew the contents from the exposed label. After I listened to the doctor's tirade, I asked, "Are you serious that he's dying?" The doctor said, "No, but he's pretty damned mad. His asthma has been out of control for a week." I finally asked the doctor the question that was uppermost on my mind: "Which pharmacist's name is on the bottle?" It turned out to be my partner's name. I told the doctor that I was not responsible for the error, so he backed off. I found out later that my partner was indeed sued.

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