Reader Pattie got the wrong pills from CVS and luckily, she noticed before taking them. She has no idea what they were, but is wondering if this sort of mistake is common.

Pattie says:

Today I picked up my medication from CVS Pharmacy, it’s something I’ve taken for a couple years now so I’m familiar with what the pills are supposed to look like. When I got home with the bottle of pills and went to take one, I found that they looked all wrong. My pills are blue oval pills and rather large. These pills were small round gold pills. It’s written on the bottle what they are supposed to look like, and the bottle said, “blue oblong tablets.” I have never noticed this description before but I now see (looking at old empty bottles) this has been on there for some time. I wonder how many other people don’t read the description.

I returned to the pharmacy with the bottle of pills and the pharmacists seemed confused but not concerned or terribly apologetic. They did say they were sorry, but that did not explain to me how this happened. What if I couldn’t see? I’d have taken these mystery pills and who knows what could have happened to me. Don’t pharmacies have double check policies to make absolutely certain that what is in the bottle is the proper medication? How often does this happen?

It’s hard to actually know how often this happens — because pharmacies are not required to report errors to any regulating agency.

A 2007 20/20 investigation found that “in more than one in five cases, chain pharmacies made some type of error in filling their prescriptions,” which, of course, is totally terrifying.

ABC says that none of the errors that they found were as severe as yours, (they were never given the wrong medicine) but their report apparently saved someone’s life. A mom saw the investigation and checked her son’s meds — only to find out that he’d been on the wrong pills for three weeks.

Ramirez said she filled her son’s prescription for a drug called Tegretol-XR, which was prescribed to treat her son’s mental health problems, on March 15 at her local Walgreens. But her child’s condition worsened, and his doctor told her to increase the dosage.

It was not until a friend suggested she view the recent ABC News “20/20” report on pharmacy errors on The Blotter on ABCNews.com that Ms. Ramirez thought to double-check the prescription.

To her horror, instead of Tegretol-XR, Walgreens had given her Toprol XL used to treat high blood pressure in adults.

Apparently, had this gone on for much longer, it might have been fatal.

So pharmacy errors happen. Drugs sound the same, doctors scribble, and pharmacists don’t have magical bad handwriting deciphering powers. They’re also human beings who make mistakes.

Consumer Reports Health has some tips for preventing pharmacy errors from harming you or your family. Check them out.

Prevent drug mix-ups [CR Health]
Results of the ABC News ’20/20′ Undercover Pharmacy Investigation [ABC News]
New Pharmacy Error Found at Walgreens [ABC News]
(Photo:Spidra Webster)

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