Horrible accident. I assume the situation is something like... pharmacy supply bottles of each of these are right next to each other on the shelf or something.

My wife and I have lost three pregnancies... one was a stillbirth. Although they were all natural losses, you cannot put a price on this.

I hope that she wins and wins big. Money won't make her feel better, I know. But Walgreens needs to pay for this.

@InThrees:
or more like doctor's handwriting illegible.

hold off on filling the prescription until the doctor can be called to verify his/her illegible handwriting. Pharmacists shouldn't have to guess.

@protest:

But if the doctor's handwriting was illegible, wouldn't it have made sense for the pharmacy to verify the prescription with the doctor's office?

@Consumerist Moderator - ACAMBRAS: Agreed. Especially if the pharmacist knew (which he should) that this pregnant woman was either supposed to get vitamins or a drug that would obviously have detrimental effects on her unborn child.

After reading this, I felt so sad. I also hope she wins for this HUGE mistake. Besides, I can't remember when I read an article, but this year it came out an ordinance where the prescriptions must be legible.

Both my GP and a specialist I see attach a computer-printed copy with the handwritten prescription so the pharmacy staff never have to guess. Why isn't this common practice yet?

I believe the pharmacist to be ultimately responsible, HOWEVER This story really illustrates the need for women to mind absolutely everything you put in their body when pregnant. As sad as it is, if she had checked the label and the drug info that were given with the bottle she might have been able to prevent this from happening.

I guess "whoops" wouldn't quite cover it.

That's pretty horrible though.

@MystiMel: What about, if she just got this new prescription, the pharmacist has to double check her medicine. Also, if she had a refill in the past, the pharmacy must have that information as well.

@MystiMel: Who says the label was wrong? When I read the article I assumed that the pharmacist put the wrong pills in the bottle. The label could have been correct.

For as long as I can remember I've always verified the inscription of the pills with what they are meant to be (according to the drug info).

Sounds like Mr. Gower has been drinking again. Too bad George Bailey wasn't around to stop him from mixing up the medications.

I'm not totally aware of the standard practices here but wouldn't have the instructions for the chemo medication mention what it is used for? I mean, hodgkins disease vs. pregnancy, two very different things. I always read instructions, she had to read them to know what her dosage was.

@MystiMel: I'm under the impression that the pharmacist doesn't just GIVE her the bottle, he/she gives her the required dosage in a standard bottle, and prints out the label himself. If thats the case, the incorrect pills could have been given in the correct bottle. They themselves filled it wrong & there was no way this woman would have ever known unless she was a licensed pharmacist & dealt with pills on a daily basis. Which she was not, so she holds absolutely no responsibility for this whatsoever. I hope she gets a hefty amount from them, this is horrible.

@CoffeeCup: Normally, upon filling a new prescription, the pharmacist or assistant gives her the instructions orally, describes when to take them, how much. Could have been the pre-natal label but incorrect pills actually in the bottle.

About 2 years ago, the practice where I go to see my GP switched to an electronic prescription system. The docs type in the prescription, print it out, and sign it. Illegible prescriptions are no more. Prior to that, trying to read the handwritten scrips was heinous. I can only assume that pharmacists were somehow used to deciphering it, because I never got an incorrect prescription.

If it weren't so pathetic to watch the transition to electronic records it would be hilarious. Only after I sat in an exam room and watched my doc laboriously peck at the keyboard with two fingers did it dawn on me he was just barely computer literate. He is not that old either, so it's not like he's 50 years behind the technology curve.

The article is not clear on exactly what happened. Did Matulane get put in a package labelled Materna, so there was no way for anyone else to catch the mistake? Or did the prescription actually get filled and labelled as Matulane?

I have a good friend who is a pharmacist for CVS. In their system, a picture of the correct pill comes up on the screen when processing the order. When you get the instruction sheet home, there is a picture of the pill right there in the sheet.

This was avoidable on several levels. Its Walgreens. Its not likely that the pharmacist was the only one touching this bottle. Typically there's a (lowly paid) pharm tech who fills it and the pharmacist verifies it. She also mention that this kind of thing happens more often than you'd like to know.

ALWAYS check your pills.

Also, if this was her first prenatal script she wouldn't have known what the pill looked like anyway, so she would have probably assumed that the pharmacist was correct.

Good Lord that's horrible. You would hope Walgreens would take more precautions.

My wife always has me go to the pharmacy to fill new prescriptions, since I have more knowledge about meds than she does. Our doctor has semi legible hand writing, so I look at the actual script before getting it filled, just to be sure.

As an aside, one of the attending doctors at the nursing home where I work has the absolute worst hand writing I have ever seen. I always try to look through his orders before he leaves so I can clarify anything I am not sure about. I imagine pharmacists learn how to read bad writing.

@homerjay: I have a good friend who is a pharmacist for CVS. In their system, a picture of the correct pill comes up on the screen when processing the order. When you get the instruction sheet home, there is a picture of the pill right there in the sheet.

That's how it is at every pharmacy. But if the prescription is entered into the system incorrectly, then the incorrect pill will show up on the verification screen.

When you get a prescription filled, you are going to get whatever was inputted into the computer. 99% of these kinds of errors come from someone typing in the wrong drug/dosage/strength when they are inputting the prescription.

Obviously, there's a lot of blame to be thrown around here. It just stresses the need for every person in a health care profession to be extremely careful. For all you doctors out there, this just goes to show you that the godawful practice of scribbling out prescriptions in nearly illegible chick scratch can get patients killed. And for all you pharmacists and pharmacy techs out there, patient safety should always come first, not filling a high volume of prescriptions as quickly as possible.

Given that I have firsthand experience with the latter, I can say sadly that many workers in pharmacies lose sight of this.

@homerjay: I take claims all the time for miss-fills. Most of the time, they catch it before the patient actually ingests the pills, but I've never seen a claim as serious as this. It's horrible. If this was her first pre-natal script, then theres no way she would've known. I'm assuming its the job of the licensed pharmacist to catch these kind of mistakes, especially if they just filled the bottle with incorrect pills but the labeling was all correct.

And has anyone that that maybe they DID input the correct pill/dosage, but when the pharmacist/pharmacist tech went to fill it, they just mistakingly grabbed the wrong bottle? They both seem like they would be next to each other, Matulane & Maturna. Its quite possible.

Interestingly, I just took a look at the one prescription I have, and the pills actually have the name of the drug printed on the surface of the pill. Maybe that's a better idea than these cryptic codes and abbreviations.

They most likely were right next to each other on the shelf because they usually do it alphabetically. But I used to work in a pharmacy and I know that the prescription is (or is supposed to be) checked, counted, and re-counted at least 3 separate times between the pharmacist and the tech. Prenatal pills are pretty common so you would think at least one of them would have noticed the mistake during one of the counts. If they're that spaced out, they definitely should not be dispensing drugs. The pharmacist that I worked with was so attentive that he often caught dangerous drug interactions that the doctor had missed. And this was way before we had the computer systems that automatically detected interactions and/or showed pictures of the correct drug.

That poor, poor woman. I hope she gets a huge settlement, although that can never make up for this kind of loss.

Pharmaceutical company to market cancer drug as morning after pill in 3 - 2 - 1...

@Hambriq: Wait, I thought the Rx was run through the system correctly but the wrong pill was put into the bottle...?

I'm confused.

It's an obvious mistake but a hugely damaging one. It's hard to know how to safeguard against this kind of thing, the obvious solution is requiring a doctors ok on damaging drugs but that could end up taking too much pharmicist and doctors time to be practical.

How about they have a number code for each form of medication? Stock filling for supermarkets requires the use of UPNs to ensure produces are in the correct place, how about giving each prescription a code which can be checked to ensure that if a patient requires rolisian they're not given rolislan (names made up)

Materna is a small tan tablet that looks like a multivitamin with Materna M-55 embossed on it.

Matulane is an ivory capsule that has MATULANE Ï? sigma-tau imprinted on it.

I found this information after spending about thirty seconds with google.

While it is inexcusable that this occur, it is still quite plausible that this was simple, blatant human error. It's human error that should cost somebody a license and a career, and a company a large amount of punitive damages, but it's still human error.

I would not trust any new medications ( or any different-looking old medications for that matter ) without checking some sort of physicians reference first, especially with a responsibility as important as an unborn child.

In that, it's as much the woman's fault for being an uninformed sheep popping whatever pills she's handed with the trust that they're correct as it is the pharmacy that provided the wrong pills to begin with.

@Draconianspark: Congratulations. It took 30 comments, but someone finally got around to blaming the victim.

@homerjay: Thats most likely what happened but some people are trying to blame the lady for not checking her pills. As if she would know the difference but whatev. Theres always going to be victim bashers.

@cryrevolution: Wouldn't not knowing prompt you to take a leap of faith and, well, find out?

I can only see two scenarios, one in which our prospective mother has taken this medication before and one where she has not.

In the one where she has, wouldn't the sudden transformation of her medication from a brown vitamin tablet to an ivory capsule raise an eyebrow?

In the one where has not, wouldn't it be pertinent to check the Internet for any possible complications and/or side effects before starting the new medication? Perhaps along the way she can discover that the capsules she has are not a prenatal vitamin.

Granted, this should never have happened. I expect to see a pharmacist loose their license to practice, and I expect a huge settlement and punitive damages paid out by Walgreens' insurance.

That doesn't change the fact that she took pills without learning about them on the faith of the competence of a retail pharmacist.

In fact, I'll wager that this very same woman more meticulously checked the validity of a drive through order before leaving the window than she did her medication, and the only thing separating those two fields of retail is a decade long nap in medical school.

I get refills at Target all the time, and even if this wasn't her first refill, generic pills change all the time. My lisinopril has change two or three times in the last five years as Target has gone to different suppliers. So has some of my diabetic medication.

I don't think that it's at all unreasonable for a person to assume that the controls worked at her pharmacy and that she could trust she was getting the right medication.

Frankly, I'm not sure if you asked the average person they'd have a clue how to check out their medication themselves. Those that have some knowledge would probebly think about the PDR, but you have to *have* one. A recent one, at that.

@Dr. Eirik: www.rxlist.com

Also most pharmacies I have used retain a copy of the PDR and have no trouble allowing you to see it.

Call me paranoid, but I tend to double check if the pills do so much as change color.

If the shape of the pills change over time, the name printed on the medication... (in these two medications they are both printed with the name) won't change. I agree with draconianspark here. If I was pregnant I'd be careful about everything I put in my body, especially medication.

walgreens messed up my prescription too. they gave me orthro tri cyclen instead of orthro cyclen. didn't even apologize about. and i never would have known it was the wrong scrip, except for that i'd been taking the same thing for 2 years.

they are evil. that's why i go to target pharmacy. they recognize me when i come to the counter. i thought all pharmacists were rude, but then i realized, it's just the ones at walgreens...

@rexforever: I don't think they're evil. Its just that every industry has their fuck-ups. if you're a fuck-up in sales, all that happens is that you don't make much money.

The problem with pharmacists is that there is a huge shortage and the asshats are still working. The good thing about the Target pharmacy is that they're not overworked. They're not filling hundreds of Rx every hour. They're filling 10's.

They have time to double check- even if they're retarded.

@rexforever:
Your experience is not company specific, its store specific.

What you said about Target is what most people say about Walgreens.

There is a shortage of pharmacists, every drug store will higher anyone with a pharmacy degree. They need pharmacists to have their pharmacy's open so they do not care what their personalities are.

What is terrible in this case is Walgreens will be screwed when the pharmacists is fully to blame here.

Whats worse is this will probably be settled out of court and the pharmacist will keep his job because they cannot afford to fire a pharmacist.

That's really awful and I feel really bad for her and her husband. We trust our doctors and pharmacists to take care of us and look out for our well being because they are the ones who have been through the intense education required to do what they do. You certainly can't expect a patient to catch everything themselves. She definitely deserves something for this as I'm sure it has caused a lot of emotional problems and depression. In order for Wallgreens to save face, they really should just admit their mistake and try to come up with something they could offer her to try and make up for it instead of going the court route. I'd be amazed if any judge took Wallgreens side if it does go to court though... Anyway, Mixing up a vitamin with a chemo drug sounds very dangerous and mistakes like this could potentially KILL people depending on the medicine involved. I believe pharmacists should always check and double check everything before handing over the medication to the patient ESPECIALLY if the patient happens to be pregnant.

@Draconianspark:
Wow -- just, wow...

I'm not one that supports the suing of individuals and companies over frivolous things, as are 90% of cases in courts these days (pulled that statistic out of my ass).

However, the pharmacist is grossly negligible in this case.

@lestat730: The sad thing is that pharmacists do indeed check and double check everything before handing medication over. This is a relatively minor case of this kind of occurrence. People do die from events such as this. Frequently. This girl is lucky that she wasn't given something like

There is absolutely no saving face for Walgreen's here, nothing they could do could make up for the loss of a life. They would be a bunch of idiots if they let this go to trial.

Also, admitting that this was a mistake opens up a hotbed of liability that their legal team will have to weigh carefully; this is a situation that could potentially manifest criminal charges depending on the state's laws and the aggressiveness of the resident DA/Grand Jury, which I am no expert on.

As far as care-givers being trustworthy; Don't trust anybody with your well being save for yourself, because your well being is not relevant to anybody else's interests.

As I said before, we wouldn't be having this conversation if this person took 30 seconds to type the word written on the pill into google and reading about it before putting it in her mouth.

What would really help us Consumerists is some links to some drug identification websites so if we have some meds we can go right to our bookmarks.

i like that RxList

Okay - confused here a little bit. There are alot of questions that appear to not be answered. I know the local Walgreens not only prints on the bottle label what the pill looks like (ex. Round white table, Side 1: Side 2: , etc), they also provide a pretty descriptive little insert that includes the general information about the medication and what its supposed to do.

Not that I'm taking Walgreen's side on this because they did make a mistake, but was the bottle labeled correctly or did it carry the label of the incorrect medication?

Don't know about the rest of ya'll, but I always make sure that the little description printed on the side of the bottle matches whats inside and that the name of the drug on the bottle is what was prescribed.

With the information available so far, it is difficult to discern what information was provided by the pharmacy regarding the script.

@timmus: [www.drugs.com]

here you go.

@Dick.Blake:

Pharmacists are not vending machines. They are trained medical professionals and they are responsible for the miedicines they dispense.

That's why pharmacists can call the doctor if they can't understand the writing.
That's why pharmacists are trained not to give miscariage-causing drugs to pregnant women.
That's why they check to make sure there aren't dangerous interactions between the various drugs you are taking.

Yes, the pharmacist is 100% responsible here.

@rdm24:I am certain that this particular event was contrary to the training of this particular pharmacist, but it happened anyway, and it happened in a way that one can objectively look at the situation, however unfortunate, and say "I can see how that can happen" as they are very similarly named medications.

In a perfect world, yes, this would never happen. Realistically though, would you rely completely and blindly upon the integrity and infallibility of one person who is, as you say, 100% responsible for dozens, if not hundreds of different prescriptions being filled every day?

I certainly don't, and within my immediate family there have been at least two occasions where mis filled prescriptions or interactions with correctly filled prescriptions would have been injurious if not fatal; each time was circumvented by a quick check in the PDR, and more recently the internet equivalents.