Another way a correctly prepared prescription can be given to the wrong customer is when pharmacy workers select the wrong bag of medicines for customers. The process of identifying the customer can be incorrect if both a full name and date of birth are not asked for and provided at the time of sale. Some pharmacy workers believe they know their customers by sight and have not developed the safe habit of always asking customers to state their full name and date of birth. Or, caregivers, friends, and even family members who pick up prescriptions for the patient may not know the patient’s date of birth. Thus, the wrong customer’s bag may be chosen if there are medicines in the pick-up area for customers with the same or a similar last name. Using an address to identify customers is not ideal, as people with the same last name often live together.    

If you do not notice the error and take another patient’s medicine, it could be a medicine that should never be taken given your current health condition, allergies, or other medicines you are taking. For example, a pregnant woman who intended to fill a prescription for an antibiotic to treat an infection was accidentally given another woman’s prescription for methotrexate instead. Both women had the same last name and very similar first names. The pregnant woman took one tablet of methotrexate before noticing the error. Methotrexate is a medicine used to treat certain cancers or other conditions such as rheumatoid arthritis and psoriasis. The medicine prevents cell growth and should never be taken by a pregnant woman. It can cause birth defects in the brain, bone, and heart, or cause a miscarriage. The pregnant woman was seen in the emergency department, but it was too early to determine if the unborn child had been harmed.

Another problem with receiving and taking the wrong patient’s medicine is that you may not be taking the correct medicine prescribed for you. This can lead to untreated health conditions that can worsen over time or cause other adverse effects on your health. For example, a patient who had been prescribed an antibiotic for a serious bacterial infection accidentally received another patient’s medicine, sertraline (Zoloft), to treat depression. After 10 days, the patient became very ill as the infection raged on untreated. Another patient had been prescribed a pain reliever but instead received another patient’s prescription for allopurinol, a gout medicine. After days of pain without relief, she noticed the error and called the pharmacy to correct the mistake.   

Customers who are accidentally given the wrong patient’s medicines have occasionally misused these medicines for recreational purposes or to harm themselves. In one case, a customer went to the pharmacy to pick up prescriptions for an allergy medicine and oxycodone, a narcotic pain reliever. The pharmacy found that the prescriptions had accidentally been given to another customer. When this customer was called, he denied receiving the wrong prescription, presumably because of the oxycodone—a common drug of abuse. In another case, a woman who had picked up a prescription for Premarin (estrogen) found another patient’s medicine also in the bag when she arrived home. The medicine was amitriptyline (Elavil), a medicine to treat depression. Later, a pharmacist received a call from a local hospital to tell her the woman was in the emergency department after taking 30 amitriptyline tablets dispensed by the pharmacy for another patient, in what appeared to be a suicide attempt.

Another unfortunate aspect of this type of error is that confidential information is shared with the person who receives another person’s medicine. The full name and address of the patient, along with the drug name, are on the pharmacy label. For sensitive medicines, such as psychiatric medicines or medicines that treat human immunodeficiency virus (HIV), patients may be deeply troubled that another person is aware of this information.       

So yes, these errors do happen and they are not uncommon, as nearly every community pharmacist would admit. In my next blog I’ll detail easy steps you can take to prevent these problems from affecting you or a member of your family. 
Read more at http://www.philly.com/philly/blogs/healthcare/Getting-the-wrong-persons-medicine-at-the-pharmacy.html#gHlpwI9yGGAWbLSt.99