Should Rob Complain About His Bad Kroger Pharmacy Experience?

Rob’s local Kroger pharmacy screwed up the prescription on his kid’s TamiFlu. Rob caught the error before any harm was done, and he’s not the confrontational type. In fact, he’s wondering whether he should just drop the whole matter. Here’s your chance to convince him otherwise.

I have a 3-month-old foster son that was just hospitalized for a few days with a fever and cough. The hospital released him with a prescription for TamiFlu at 1mL twice daily. The pharmacy (Kroger) gave me a decent sized bottle with the label reading “1 teaspoon (5mL) twice daily”. Luckily, I remembered the hospital discharge papers and only gave him 1mL. I called the pharmacy to verify that the concentration of TamiFlu was correct and I wasn’t underdosing or overdosing him at all. There was some confusion and I was told I got the correct concentration, but they accidently entered 1 tsp instead of 1mL. A standard “sorry for the mistake” was given.

My mother, a nurse, was livid and said I should go talk to the head pharmacist in person and demand some kind of a refund. (The prescription cost me 167.00. I found out later the pharmacy didn’t contact the insurance correctly and it should have been covered at 100%.) I’m going to go back and get a refund anyway since the prescription is covered, but I hate getting into face-to-face conflicts. I usually resort to emails to managers. My question is, should I even escalate this? I know that I could have seriously injured the baby had I overdosed him, but no injury was actually done. Should I just let it go?

I’ll start! Rob, everyone makes mistakes, and this was a typo and not an “oops that’s the wrong drug entirely” type of problem. But simply for the security of other customers, it seems to me that someone higher up than the pharmacist needs to know what happened.

What if this is part of a pattern of mistakes? What if the typo, as well as the insurance glitch, are signs of poor training? What if you don’t complain and the pharmacy makes a similar error with someone else who doesn’t catch the mistake in time? Yeah, that would suck.

You don’t have to go get in a fight with the pharmacist. Find out the contact info for someone higher up, and send an email similar to the one you sent us. And if nothing happens after that, you might want to find a different pharmacy that you can trust more.


Edit Your Comment

  1. Admiral_John says:

    I say no harm, no foul. You caught the error and clarified it with the pharmacy. That’d be the end of it for me.

  2. MaelstromRider says:

    Definitely complain about it. It doesn’t matter that you caught it and no harm was done. Typos in medicine dosages can kill people.

    • RedwoodFlyer says:

      Exactly. When my aunt was going through nursing school (pre-union days) they had a a zero-tolerance policy for wrong Rx’s. True, everyone makes mistakes, but when you know your job is on the line, you definitely take a little more precaution.

  3. Chinchillazilla says:

    Please complain. Too much Tamiflu might not hurt someone (I don’t know, and a cursory Googling turned up little, but whatever), but if they do this with someone else who doesn’t pay as much attention, someone could get really sick. Or, you know, die.

    • ekzachtly says:

      A 3-month-old kid? Absolutely. It’s hard to tell what dose the kid is actually getting if we don’t know the concentration, but there’s a reason that the drug has a pediatric dose.

  4. idip says:

    I would talk to a manager about this.

    The simple reason is, we (most of consumers) do not have medical training. We RELY on the people with medical training to fix us up and to dispense the correct medicine.

    Some of these medicines and have some crazy side effects. Granted this one was the same drug that was prescribed, but what if the incorrect dosage was given and someone was indeed harmed.

    Pharmacies CANNOT have a 90% effectiveness… a 95% effectiveness…. in fact, pharmacies MUST have a 100% effectiveness because their actions can determine if the medicine makes you better… or makes you worse…

    Don’t get in a fist fight, or yelling match, but politely explain to the pharmacy that you as the patient rely on their 100% effectiveness and their extensive education to receive the proper prescriptions and dosages that have been prescribed to improve your health.

    • jesusofcool says:

      I agree that he should bring up the issue to the pharmacy manager when he gets his money back in a polite way. But personally, I think he needs to bring up the issue to the pharmacy’s head manager before he goes to a higher power like a state regulatory committee or company executives as Chris and some commenters have suggested. First of all, it gives the pharmacy manager a chance to explain their process, offer an apology and investigate or punish the employee who committed the error. Rob can still escalate the situation to a higher power if he feels the serious nature of the crime warrants it or receives an unsatisfactory response from the pharmacist, but at least he’s giving the pharmacy manager a chance to investigate and rectify the situation.

      • JonBoy470 says:

        I think calling what happened a “crime” is going a bit too far. First of all, pharmacy errors of this type are more common than you think; the fact that most doctors’ writing is illegible scrawl certainly contributes to this. It’s entirely possible that the pharmacist (or more likely, pharmacy techician) who filled the script mis-read the it initially, due to the writing of it being barely discernable from a toddler’s scribbling.

        Don’t make a federal case out of this. Where the OP needs to return to the pharmacy anyhow to have the prescription cost correctly billed to his insurance, he can ask to speak to the head pharmacist and explain his concern.

  5. ColoradoShark says:

    Focus on this quote from the orignal post:

    “What if you don’t complain and the pharmacy makes a similar error with someone else who doesn’t catch the mistake in time? Yeah, that would suck.”

  6. AustinTXProgrammer says:

    I had a pharmacist make a wrong drug mistake, and she refunded all of the money and self reported to the state (she was the manager).

    I would assume that also increased the amount provided, greatly increasing the cost to you and/or your insurance

    • wrjohnston91283 says:

      I wonder if your state has self reporting requirements – that would be a good law. If a pharmacist knows they made a mistake, they must report themselves. It would be somewhat self policed, as the patients who also notice mistakes would report pharmacists, and the state would be able to match them up to see if the pharmacist reporting the mistake. The patient would have to certify “I informed my pharmacist of the mistake on XX/XX” so the state knows the pharmacist was indeed informed.

  7. Ilovegnomes says:

    Rob, please escalate this. You can be nice about it and not confrontational. Just approach whomever is in charge and tell them that you want to bring it to their attention that this happened so that they can take preventative measures to avoid this with yours and other customer orders in the future.

    If you need a why… imagine finding out that someone at that pharmacy is being sloppy, some other patient doesn’t verify their meds and dies as a result of it. You are going to wonder if raising some attention could have helped prevent that death.

  8. Megleris says:

    Tell them! Find out the contact info of someone higher up, and let them know what happened! Pharmacies need to be held accountable for the mistakes they do, so that they can evaluate if a specific pharmacist is doing their job correctly. Maybe it’s a one time thing and it’s no big deal – maybe it happens all the time and something needs to be done about it. YOU don’t know, but the store should.


    A 3-month-old baby given FIVE TIMES the recommended dose? Holy crap. I can’t imagine the harm that could have been done to that baby if Rob had simply trusted the pharmacy.

    I wouldn’t just let it go. A “simple typo” isn’t necessarily simple when it comes to things like this. I would go higher up. Maybe Rob’s baby escaped unscathed, but someone else’s baby (like one whose parents do not speak English as their first language) might not. And I certainly wouldn’t use that pharmacy again. Two pretty big mistakes on one prescription spells bad training.

  10. MedicallyNeedy says:

    George Bailey would tell the Pharmacist directly.
    Watch that he doesn’t slap you in your bad ear!

    Seriously though my CVS just got a new computer system that is “slower” then what they had.
    I was told by a pharmacist that corporate want’s it to be difficult to enter codes.
    They are always screwing people. The more they charge they easier it is to code it.
    It takes at least 10 minutes to code in for my anti-rejection meds even though I’ve been on the same plans for years! They’ve lied to me, overcharged me, and denied me too.

    • Shoelace says:

      CVS pharmacy has lied to me, made me wait unnecessarily long when I was very ill, and most recently gave me half the number of pills my doctor had ordered (I spoke to a manager who said he’d look into it and get back to me – he never did). I now take my prescriptions elsewhere. I also make significantly fewer other purchases at CVS since I’m not getting my prescriptions there. I’d say they’ve lost about $1000-$2000 of revenue per year as a result, which may not matter to them, but if enough people get similar treatment and leave maybe they’ll start to change.

    • 339point4 says:

      I wonder if it’s a regional thing? I use CVS pharmacy as well and they have bent over backwards to make sure that my family has whatever meds we happen to need.
      I recall one incident where my own procrastination led to a sticky situation when I showed up late one night to buy meds I needed for the next day and my store was out. They called around to all the CVS stores nearby until they found one that was in stock, forwarded the prescription, and personally spoke with the pharmacist there so they knew I was coming. When I got to the store about 5 miles away, they knew who I was and had meds ready for me.

      • cluberti says:

        Agreed – the local CVS here does everything they can to make sure we get our prescriptions on time, and since my son is on lifelong medications, anytime he’s up for something from the doctor they always check to make sure of any drug interactions, etc (and they did catch something once last year that would’ve been very bad for the boy). They’re polite and courteous, which is something the folks at Wal-Mart and Walgreens are not.

        It must be regional (or maybe even store-by-store, I dunno), but I’m lucky to have a good pharmacy here for the family.

  11. windycity says:

    You don’t have to make a big screaming spectacle of yourself to make your point. It doesn’t have to be a squirmworthy moment – for you anyway. Ask to speak with the the individual in charge of the pharmacy department, show them the bottle, show them the hospital discharge order, explain that thankfully you caught their error, and ask that something be done. Whether you would like that something to be a formal explanation, some sort of retraining for whomever filled the script, disciplinary action, or a simple apology, that is up to you. Then, follow up that conversation with a letter or email to someone at corporate and be sure to cc whomever it is you speak with at the pharmacy.

    Oh yeah, and get your money back!

    • Kuchen says:

      Exactly. You don’t have to be accusatory. Just explain what happened, showing the bottle versus the discharge papers.

      A “typo” on a prescription drug is a big deal. There should be safeguards in place to ensure such errors get fixed and don’t make it to the consumer. Clearly, those safeguards failed in this case. Yes, no one was hurt this time, but someone could be hurt the next time it happens. Reporting it is the responsible thing to do.

  12. kathyl says:

    Why is a typo not as bad as giving the wrong medicine? If a typo leads to a larger dose being given to the patient, that can be just as deadly as accidentally getting blood pressure medication when you were supposed to get Tamiflu or something like that. People are human, but I think a field like Pharmacology requires a little more double-checking (and certainly more than an “Oops! Sorry, I guess,” when a mistake is made) in order ot keep people safe.

    • Kuchen says:

      It’s just as bad. Any pharmacist or nurse will be able to tell you the “5 rights” of drug administration, and they’re all equally important.

      -right patient
      -right drug
      -right dose
      -right route
      -right time

      • Sure I could agree with you, but then we'd BOTH be wrong. says:

        Right Path is sometimes funny. Often when I get pills prescribed, the instructions are “Take one pill every x hours, by mouth”

        I always think to myself, “What else would I do with these pills, shove them up my @$$? (unless it was a suppository!)

        • KTK1990 says:

          Some people need to know that.

          I read somewhere on the Dawin awards about some lady actually doing that (inserting pills that way) instead of by mouth.

          I would suggest the person in the article, politely speak to the guy in charge, and notify them of their error and if the guy is a jerk and mean, then report them.

          These kinds of errors can kill someone.

        • katstermonster says:

          I’ve heard horror stories about women taking the Monistat ovules by mouth. YUCK.

        • kalaratri says:

          I had the opposite issue. I was prescribed a suppository because I was dealing with severe dehydration and I almost didn’t read the package and took them by mouth.

        • TacoChuck says:

          I always wonder how I am supposed to take one pill five times, after I take it the first time it’s pretty much gone.

  13. tuxclam says:

    Generally I’d say that any time you “complain” to a company you’re doing them a favor. True, many such “favors” are diluted with frustration, anger, etc., and also true that many companies don’t really know how to deal with customer feedback. Even if you’re asking for a refund, there is a value to the company, if they choose to pay attention.

    A good captain would rather know sooner than later that the ship is sinking.

    And yeah, mistakes happen. It’s a part of being human. But there are ways to reduce mistakes, and the first step is to detect the pattern.

  14. hunter3742 says:

    As someone who works in the medical industry, and grew up in a family with four generations in it: report the problem. Immediately. And to the highest authority you can. This kind of thing is not a joke. It indicates poor training and/or control processes at the pharmacy you went to, and needs to be addressed before it causes somebody serious problems.

    This is what is called a “Sentinel Event” – an issue that arises at a medical facility that may or may not cause harm to a patient that causes them to re-evaluate their processes to improve patient safety. If the pharmacy is worth the paper their licenses are written on, they’ll be genuinely grateful that you brought the problem to their attention and gave them an opportunity to fix it prior to it causing major harm.

  15. Fred E. says:

    Medication errors should always be reported in the organization in which they occur.

  16. KrispyKrink says:

    If Rob’s the type to look the other way if this happens again resulting in serious harm or death to some other child, then by all means hide in your cave.

    If not, then make sure higher ups know about this mistake. Pharmacists and their techs are regulated and trained for a reason, to make sure these things don’t happen. And when they do, the person responsible needs to be reviewed before someone gets hurt.

  17. tmds3 says:

    O.K as a pharmacy tech for 10 years, they dropped the ball all the way around,
    1. They miss typed the dose
    2. The Pharmacist did not check the script to ensure it was correct.
    3.What if this had been a pain medication that could have killed your child.

    Talk to the manager and Pharmacy manager

  18. morganlh85 says:

    Once at a CVS Pharmacy we were given the ENTIRELY WRONG PERSON’S PRESCRIPTION. The guy hadn’t heard the name correctly and instead of ASKING us he just basically gave us a random prescription. It’s a good thing the pills were drastically different than the last bottle or we might not have noticed! I never trust pharmacists anymore…I triple check everything.

    • coffeeculture says:

      It’s the weak link in the system…the person giving your script at the cash register was probably a fresh-out-of-high-school clerk with no appreciable experience at all.

      I would know…I’ve done it before, I felt horrible.

      • mythago says:

        Then the problem is that the pharmacy isn’t training fresh-out-of-high-school clerks properly. It’s not hard to drill into even a callow young clerk that they must ALWAYS check that the name on the prescription is correct.

    • K-Bo says:

      They always ask me for my address to verify it matches the one on the prescription before they hand it to me. But since I moved 6 times in 4 years, I always look like an idiot trying to remember my address.

  19. Skipweasel says:

    Do you not double-check in the US? All the UK chemists I’ve been in have someone dispense and a second person reads the prescription to double-check that what’s been packed is what’s on the scrip.
    That would seem like a fairly basic precaution.

    • ekzachtly says:

      The law says a pharmacist has to check the prescription at some point down the line. Good practice says that pharmacists would generally check each others’ work as well, but if the pharmacy is busy, they’re (legally) allowed to check themselves before dispensing it. Not the greatest idea, but you would hope that most would take the few extra seconds to read carefully.

    • Fred E. says:

      Sometimes errors happen even when someone double checks a prescription. In the U.S. it there is usually a pharmacist working with several pharmacy techs who assemble the prescription. After checking hundreds of prescriptions a day, it is easy to overlook something like the incorrect unit on the dose. I don’t know about pharmacists, but nurses always check the Five Rights of Medication administration:

      1. Right patient
      2. Right medication
      3. Right route
      4. Right dose
      5. Right time

      Problem is, if the doctor writes the wrong thing, none of this matters. Sometimes a wrong prescription (say, 10x proper concentration on chemotherapy drugs) slips by the pharmacist and the nurse. Oops.

      • cluberti says:

        That’s not “oops”, but it is likely another 4-letter word: “dead”. Mistakes happen, but this one was probably avoidable. If I were the OP, I would indeed politely go to the pharmacy manager and explain the situation, as well as report it to any state or county agency to make sure this happens to no one else.

  20. PsiCop says:

    I have also gotten a prescription that had a direction-label error. This case — and mine — is not a big deal, because in the end it was just a typo and the OP — and I — caught it anyway, but there’s a reason it happened, and the pharmacy manager needs to know about it. It may be nothing more than the dispensing pharmacist typing the wrong thing, but it also might be an erroneous “boilerplate” text or something of that kind. But whatever the reason, the only way for them to know about it is for it to be reported when it happens.

  21. Dutchess says:

    If I wasn’t going back to the store I wouldn’t say anything BUT

    Since they screwed up on something else, the insurance error, you could use it as ammunitiion of they decline your request for a refund. You can tell them not only did they screw up on the billing but they also screwed up the doseage. Demonstrates a pattern of incompetence.

    Otherwise, I wouldnt make a big deal out of it.

  22. floraposte says:

    I think you can notify without complaining, and that notion may help Rob. The question to me is whether or not the pharmacy manager actually knew of this mistake and was therefore in a position to handle it. I would imagine that its going out like that means that a procedure didn’t get followed somewhere, and the manager needs to be aware that there’s somebody skipping steps.

    It’s not a complaint because you’re not asking for restitution (save the repairing of the initial charge). But it’s reasonable to consider it important that somebody with the power to handle procedural breach knows about this to make sure it doesn’t happen again, and that’s what Rob would be doing.

  23. mizmoose says:

    This is definitely a case where you *inform* management of the problem. It doesn’t have to be a complaint, but they need to know that there were problems.

    If there’s a mistake in procedures or if someone is not properly following them management needs to know so they can help correct the situation. Maybe someone needs some more training, maybe there needs to be a change in the way things are done, maybe there’s a more serious issue. They can’t fix the overall problem until they’re informed it exists.

  24. nightshade74 says:

    A similar thing just happened to me at Publix. My two year old was given a refill
    on his epipen JR. They gave him an adult dosed epipen.

    I caught it (different color pen!) but the printed script was even for the JR dose.
    I think you’ve convinced me to report it instead of just not ever filling anything
    at the store again…

  25. feckingmorons says:

    Tamiflu is not indicated in children under on year.

    The dose for a child 15kg or less is 2.5 ml. When reconstituted the powder used to make the suspension is a dose of 12mg/ml.

    The appropriate dose for the child (although the drug is not approved for children under one) is 2.5 ml of a 12mg/ml suspension or 30 ml.

    That said, the improper insurance reimbursement is more concerning than the possible misdosage of Tamiflu.
    1ml would only be 12ml, 40% of the recommended dose. 5ml would be 2 times the recommended dose – truly a dose much more likely to be therapeutic than 1m.

    However the powder can be reconstituted with twice as much water to make a dose in which 5ml (a common teaspoon) delivers the dosage recommended by the drug manufacturer.

    So, either the prescribed dosage was wrong, or the delivered dosage was correct according to the manufacturer’s prescribing recommendations.

    That said the efficacy of Tamiflu in a three month old is doubtful.

    • mythago says:

      No, the fact that the pharmacist issued a prescription for x5 the recommended dosage is the problem. The fact that the overdose would have been harmless is irrelevant. It’s like saying if I point a gun at your head and pull the trigger, but it turns out I didn’t know the gun was unloaded, I’ve done nothing wrong.

      • feckingmorons says:

        It was not 5x the recommended dosage.

        I never said it was not wrong, I said it was inconsequential. I also said a 3 month old should not be given Tamiflu.

    • bumpducks says:

      You really should check your sources and proofread before posting erroneous information.
      1ml=12ml? sheesh! and adding water? Good luck getting the drug to stay in suspension.

      This is most likely in fact a five-fold overdose. Yes, you and the prescribing information say the recommended dose is 2.5ml for children 1 and up. The doc wrote for 1ml per dose. 5ml per dose was dispensed. Anyone can read information over the internet. It is the doctor’s responsibility to determine the appropriate dose in children this young, not yours. That’s why they get paid the big bucks.

      The only reason for ambiguity:
      The article did not state the concentration of the suspension. The commercially (un)available suspension is 12mg/ml. Roche has not manufactured any suspension for a number of months, they focused on producing the capsules instead. When a pharmacist compounds the suspension from the capsules, we have to make it in a 15mg/ml suspension to make a stable compound per manufacturer guidelines. I know, I’ve compounded it enough times the past few months.


  26. daveinthe805 says:

    In addition to getting your money back because of the insurance matter, you need to report this to the state board of pharmacists. There isn’t a percentage of tolerance when it comes to mistakes by pharmacists. A three month old simply cannot handle overdoses like an adult can. Without an official censure of some sort, the pharmacist won’t have incentive to be more vigilant when it comes to dispensing medication. You are very luck to have caught the mistake but if someone else isn’t, that patient could get hurt. Complaining to a store manager is not very effective because he/she wouldn’t want something like this to be part of his/her record and would probably bury it.

  27. BlueEyesTM says:

    I would say the issue here is what was the risk of the pharmacy instructing them to give their son 5mL of a medication instead of the correctly perscribed 1mL. Could this overdose have had a negative impact on the child, had it not been ultimately caught? Or would 5mL render the drug less or more effective than intended by their doctor? Would the child have reacted less effectively, if at all to the medication?

    So, did the pharmacy put his son at risk of any kind?

    I agree with the person above that this could signal a trend. And the next person’s medication might mean a matter of life or death.

  28. PølάrβǽЯ says:

    Oh come on people, it was JUST quintuple the prescribed dose to a 3-month old child. It’s not like a screwed up prescription could hurt anyone – oh wait…

    • npage148 says:

      Do you know the pharmacology/toxiciology of Tamiflu? Likely there would have been no acute serious acute or chronic adverse effects. They would have just ran out of the medication after a couple of days instead. You can report it if you want.

      I know everyone wants 100% perfection but noone is 100%. If you are 99.9% accurate. you are making a mistake 1 out of 1000, that is about once a week for a full time pharmacist. Sorry but it’s the truth but to make you feel better, very rarely are there serious consequences. You caught it, they did not get hurt. Report it to the pharmacy manager and move on.


      • Hoss says:

        So it’s ok if you — not a base of tens of thousands of pharmacist — but you, will make an error once a week and the mistake is not toxic it’s no big deal. Nice.

      • mythago says:

        Attitudes like yours are a big part of the reason we have tens of thousands (at least) of deaths each year due to medical errors.

        The whole point of having a system of checks is to CATCH those human errors, BEFORE they make their way to the patient. “Nobody’s perfect” is absolutely no excuse for prescribing an overdose of a drug — and the fact that this time, the overdose wouldn’t have killed the patient, is no excuse either.

        If you truly think it’s acceptable to screw up medication once a week, you need to quit your job and find a profession where you’re not likely to hurt people. The other pharmacists posting here seem to understand quite well that this was dangerous; why don’t you?

        • npage148 says:

          I never said a mistake a week is acceptable, I said it was the way it works. When a pharmacy wants to complete more scripts with less help in less time, mistakes will happen. If you want or think 100% perfection is the only way to operate then you live in some magical land. It’s what we all aim for but it’s unrealistic to expect it. Doctors make mistakes, pilots make mistakes and while none will admit that it is acceptable, it’s realistic for it to happen. Do you ever make a mistake at your job?

          Also, please reference that medication errors are killing tens of thousands of people each year, I’d like to see that statistic.

          It sucks that a mistake happened, but the father was informed and caught it. No-one was hurt and it was quickly corrected. This is the best possible outcome. I’m sure the pharmacist that the mistake was upset at themselves, I would have been too

          • mythago says:

            Oh, I see Consumerist is having more comment-eating fun today.

            Medical (not “medication”) errors resulting in deaths range from estimates of 45,000 to 98,000 per year. God knows how many result in errors short of death.

  29. Annika-Lux says:

    *puts on CPhT hat* This error occurred because a pharmacy technician entered the information wrong and filled the prescription wrong, and the pharmacist who is supposed to be checking and signing off on the pharmacy technician’s work didn’t catch it (and that’s kind of, you know, the point of them checking it and signing off on it). The pharmacist also should have noticed that the dosage was way too high for a three month old baby. As a pharmacist I know would say, “that’s a big fuck up”. Fail all around. This needs to be reported. *removes CPhT hat*

  30. Winter White says:

    This is why doctors need to CLEAN UP THEIR HANDWRITING.

    Millions of prescription errors are made each year due to illegible prescriptions.

    I’m not saying that’s what happened in this case, the hospital may have phoned it in, but it’s a problem that needs to be recognized.

    Since this was medication for an infant, I’d be a little more upset than if it were an adult where the margin for error is a little greater. I would just call the pharmacy and ask to speak to the pharmacist directly. All pharmacies have a pharmacist on duty in addition to the techs who may be preparing the actual bottles and labels.

    • K-Bo says:

      My doctors use hand held pdas to enter prescription information, the pda’s apparently make them go through screens with the medicines and dosing recommendations, so everything has to be pulled from a pre-existing database, no hand writing things in. Then it is faxed to the pharmacy. This way, the handwriting is taken out of the equation. I really think it won’t be that long before this is the norm.

    • TheLemon says:

      Nearly every prescription I get these days is either computer generated or sent directly to the pharmacy by the doctor’s office. No more blaming errors on illegible handwriting. I wonder which type Rob was given?

      Yes, he should say something. It doesn’t have to be confrontational. It can simply be informative, presented to a manager in a way that shows you are showing concern for everyone who fills their prescriptions there. Let them know how relieved you are that their mistake did not have more serious consequences (including death). Then kindly ask for your refund, and consider changing pharmacies.

  31. bumpducks says:

    Here’s my input as a pharmacist…

    Federal law (OBRA ’90) requires that the pharmacist offer counseling for all new prescriptions from a pharmacy. Did they? and did you accept? It is one of our last steps to make sure you are getting what you expected.

    Do remember, pharmacists are human beings. They are subject to both human error and system errors. Making an error like this will make any pharmacist with a soul feel horrendous. I am thankful that your child was not harmed. The pharmacist should have offered a heartfelt apology. If you did not feel like that was enough, you can ask the pharmacist what steps they are taking to prevent this from happening again. At the very least, they will let you know that they are filing an incident report with their corporate office.

    If you still feel like the pharmacist didn’t give a damn, feel free to contact the corporate office. And be prepared to shop around for another pharmacist. There are plenty out there that take the time to know your medications, to know your profile, and to know you.

    • mythago says:

      An apology, heartfelt or no, is beside the point. The problem is that there are supposed to be checks and re-checks to catch these kind of mistakes so that the patient doesn’t get the wrong dose – period. Reporting the error to the pharmacy isn’t a punishment; it’s doing them a favor.

  32. pwillow1 says:

    You caught the error… but this is a SERIOUS error. I would contact the Board of Pharmacy in your state and make a report.

    There are rarely sanctions for this type of error, but I think it’s important to establish a record. If there are enough complaints compiled for this pharmacist, they may require this person to take additional training.

  33. Extractor says:

    Just checked the PDR and as I expected, its very hard to OD on an antiviral.
    “At present, there has been no experience with overdose. Single doses of up to 1000 mg of TAMIFLU have been associated with nausea and/or vomiting” PDR statement.
    Now when it comes to Narcotics, thats another story. I always write single dosage scripts for chloral hydrate for kids- 500mg in liquid form to be taken at one time an hour or so before the appt. A few years ago, a pharmacist changed the script for some odd reason from 5cc to 30cc and include the original insructions, take all at once 1 hour before the appt. 6 times the dosage on a drug thats supposed to knock the kid out to allow me to work on him. Now thats a toughie, its supposed to knock the kid out and it did. Kid was OK at the office but began to loose it on the way home and was brought to the ER where it was discovered that the script was in error. The parents threatened me (blackmailed) for $1500 payable by April 15th of that year. I contacted Arbor Drugs at the time and they did a history on me as well as inspecting the script that had been called in. Everything backed my position since I never wrote for more than what was needed, 1 dosage. During the course of this I found that most prescribed 1 gram and thats what I Rx nowadays. A pharmacist had, for some dumb reason changed the quantity to 30 cc’s.
    Arbor Drugs admitted their mistake and the pharmacist retired the next day. We also lost the family as patients probably due to the fathers threatening letter.
    To me this next screwup was somewhat funny but it also resulted in a settlement from the Dentist and the Pharmacy. A 12 year old girl was written a RX for 150 mg Amoxicillin to be taken every 8 hrs. Due to the Dentists scribbling and the pharmacists lack of verification of just what the hell it said, 50 mg Viagra was dispensed with the amoxicillin instructions, 2 to start and 1 every 8 hours. Heard some weird stuff occured with her in school.
    Im not going to ever get nailed on a script. I write the body of the script as though I was doing some drafting which I did when I was in Jr High. When I use a bench scrpt, the ones that the pharmacists keep behind the counter for us to use when we need to write one and dont have one of our pads, the pharmacists usually are about to ask for my state licensing cards until I sign annd thats when they realize who I am. I’m not going to be the cause of an incorrect rx being filled. Nowadays at one office I handle the IT also, the Rx’s are printed by the computer and all I have to do is sign it. The pharmacist like to show other Dr’s my Rx’s and explain that this is how they should be written. An elementary school child could easily read mine.
    In this instance no harm was done but definately entitled to a full refund. My case, the pharmacist could have killed the kid. That was the only script in over 28 years to be screwed up on me and that was because it was called in. Luckily none of the other staff covered anythig up.

  34. skeksis says:

    Yes, you should definitely tell them of their mistake so that they:

    1) know that it is happening
    2) have a chance to prevent it

  35. Crutnacker says:

    Yes, complain. I recently had the experience from hell with Kroger Pharmacy, where two phoned in refills took me 30 minutes to claim, and then I only got half the order. Kroger didn’t follow up with the physician on a needed authorization and would NOT refill a couple of pills to last until they could get in touch with the doctor (it was a weekend). My pharmacy checkout guy was new and it took him forever to ring up the one prescription, which rang up without the insurance coverage they’ve had on file for years now. Despite having five people behind the counter, nobody would help him. He finally gets the price right, then can’t get it to run through their system.

    Best part, after thirty minutes to get 1/2 of what I came there for, the guy apologizes and places the blame for the length of time on the difficulty of entering my insurance information because “your carrier is one of the worst to deal with.” Sadly, the poor jerk didn’t realize that the company he felt was the worst was also my employer.

    Kroger = epic fail. Although it could be worse…. Wal-Mart (SHUDDER).

  36. Bort says:

    I’d complain, but politely, but make sure its to a person of influence, and thats the trick, finding out the correct person to complain too, if you complained to the janitor for example thats entirely the wrong approach.
    You may want to look into any kind of state watchdog or something like that, since this could be a life and death matter, its more important then for example an incorrect cell phone bill, and i would think its mortally imporrtant this type of error be prevented in future.
    If i were them i’d apologize profusely, and make it up to you, whether its a discount, or a personalized apology, that kind of thing, and if your still not comfortable going back, choose a different pharmacy in future
    Do let us know what you decide to do

  37. newsbunny says:

    Complain. You don’t have to go nuts, but complain. It’s your duty as a consumer.

    I received scripts with errors on three seperate occasions at a CVS in midtown New York, and finally called corporate to complain. Yes, I stopped using them. Why the hell I didn’t earlier I can’t tell you.

    I have epilepsy and a thyroid disorder and can’t handle things being dispensed incorrectly.

    Also, good for you Rob for catching the mistake. We all need to know our scripts and check them before we pay for them at that pharmacy counter.

    I’m lucky enough to have an actual inedependent pharmacy in my ‘hood now. They’re great.

  38. enomosiki says:

    “Sorry for the mistake” that could have left his foster child ill or, worse, dead.

    He shouldn’t bury this one. This is a prescription drug that he’s talking about, and the fact that an employee put down the wrong dosage needs to be addressed, because this sort of thing constitutes as handing out incorrect prescription, which is considered as a severe malpractice. Don’t believe me? Go take a look at how CVS is doing.

  39. Woodside Park Bob says:

    Two mistakes were made here which constitute pharmacy malpractice. First the prescription was improperly labeled. Second, whoever should have checked the prescription before giving it to the customer either didn’t check or missed the error. [There was a third mistake in billing, but that’s different.] Errors in filling prescriptions can be life threatening and are taken extremely seriously by good pharmacists. The fact that the customer caught the error does not mean this is a “no harm, no foul” situation. Kroger management needs to be notified. So does the state pharmacy board. If they aren’t notified, they cannot assess whether there is a pattern of errors with this pharmacist or in this pharmacy and take appropriate steps to ensure that standard procedures for filling prescriptions and checking them are being followed.

  40. shibblegritz says:

    Mistakes happen. But there’s less room for error in jobs that involve the possibility of harm, such as a doctor or pharmacist.

    The error does need to be reported to protect the public against the possibility of a careless pharmacy employee, but it needn’t be a confrontational situation.

    As an aside, in any case in which you are receiving a prescription for a medication that may have side effects or serious consequences, it’s good practice to ask your doctor to repeat the name of the medication, the amount and the dosing schedule to you and to write it down (I record it on my iphone). When you get to the pharmacy, ask them to read the prescription to you and verify their reading matches your understanding. If it doesn’t, have them call your doctor’s office directly. When you get the filled prescription, check the container to make sure the label matches your record of the doctor’s instructions.

    This leaves two possible error points … the doctor giving the wrong dose and the pharmacy giving you the wrong medication entirely … but will eliminate most of the more common errors, such as this one.

    A few minutes of effort really is worth it for your health and that of your child.

  41. friday3 says:

    Absolutey tellt he manager. It does not need to be confrontational, but pharmacists are dealing in life and death. What if you were in surgery and the doctor needed to move 1 cm over to stop your bleeding, but went 10 cms over? Maybe you could be dead. I don;t know the dangers or side effects of too much tamiflu, but there are plenty of drugs that incorrect dosages could have potentially fatal results.

  42. savdavid says:


  43. Kevin411 says:

    I quit using Kroger Pharmacy when the one near me had an inability to maintain confidentiality. Every time they would print a bottle label, the printer would print the details on a continuous roll of paper kept for their records. These printouts were visible through the window. I would complain each time, and they would throw something by the window to block it, but it always disappeared. Finally I had had enough. The next time I was there, I watched who was there, then looked at the paper and turned to an older lady saying … Ms. Smith, right? (She confirmed) I see you are taking Xxxxxxxxx and Yyyyyyyyy. I’ve heard of those, but don’t remember what they are for. She looked stunned that I would ask and said it wad none of my business what she was taking. I told her she should tell the pharmacist and pointed at the paperwork. She threw a freaking fit at them. A new sign advertising the pharmacy hours was glued to the window two days later.

  44. PresidentBeeblebrox says:

    Definitely complain. It could be a symptom of a larger problem at this store, and the only way they will be able to fix it is to know about it.

    This happened to me twice in the past year. Once I got someone else’s prescription for 100 Vicodin tablets. I could have had a lot of fun them, but instead I went to the pharmacist and told him. He turned ash-grey (understandably, as this is the kind of thing that the Feds get involved with) and thanked me for the report. The second time I got someone else’s Glucophage prescription. This one wasn’t easy to catch because unlike the earlier incident, my name was on the bottle but the wrong tablets were in the bottle. I thought the pills looked a little different than usual, and indeed a quick Google search of the code stamped on the pill revealed what they were. I went to the pharmacist again and told him of the error … and that I wouldn’t be coming back to the store. Had I not caught this, I would have been in a world of hurt, because Glucophage can cause serious liver damage in non-diabetic patients.

    So, yes… don’t be a dick about it and go to the state pharmacy board, but they need to know about the mistake.

  45. coffeeculture says:

    Even at 99.99% accuracy, an error is going to happen…these people are human, I’m sure they feel really bad about it. These pharmacists are science geeks and aren’t used to confrontation, I’m sure someone was crapping their pants.

    With that said, it sucks this happened to you…just go to the store and talk to the pharmacist/manager in a calm/collected way and explain your concern. I wouldn’t escalate it to the state board or anything, but the company needs to know.

  46. DAK says:

    This is very simple. It’s dangerous to misuse prescription drugs. That’s often a big part of why they’re prescription drugs instead of OTC.

    You should absolutely bring this up to the manager, and probably 3-4 steps up the food chain as well. If someone tells you that it’s ok because you caught it, or “mistakes happen”, then those people are ignorant.

    I’m not sure what the OP’s options are, but I would suggest that going to Kroger for anything, much less medication, is a bad idea.

  47. Extractor says:

    One thing eveones forgetting- Who gets the initial blame for these screwed up Rx’s? Us, the Dr’s. If the pharmacist cant read the script he shouldnt fill it and call the Dr to find out just what the hell he wrote. With all these new drugs with wierd names its tough to figure out what that patient is taking and what he can take just so it doesnt interact with anything they are taking as well as averting anything they are allergic to. I wish every med was written in is chemical ie generic form. Generics are 99.99% same as brand name for alot less. Thats why Pfizer is worried about Lipitor, it becomes available as a generic next year as well as several other meds. YaHoo!

  48. Dondegroovily says:

    The reason for the error is simple. No one in their right mind would trust the American measurement system when someone’s health is on the line. Teaspoons and Tablespoons may be adequate for making cookies, but when it comes to medicine, maybe you shouldn’t use a measurement system that’s a complete clusterfuck.

  49. User says:

    If the dude doesn’t complain, he’s nuts. Asking for a refund is pointless — he likely won’t get it. As a former pharmaceutical labeling and quality assurance guy, I assure you that drug dose mistakes are a serious and life-threatening problem. Over- or under-medicating is a serious threat and if this guy doesn’t complain then the pharmacist will not get the opportunity to learn from his mistake. The next time he does this, the drug may be different, the parent may not be savvy or may miss the error, and the kid could easily die. I’d rather live with getting a pharmacist written up or yelled at, but not making a mistake again, than live with knowing my inaction let some kid die.

  50. billhughes says:

    It is the responsibility of the patient (or caregiver) to ensure meds dispensed are correct and the dosage is correct. Sure it’s the pharmacy’s job. You want to rely on the pack of 3rd world refugees most chain pharmacies employ? Read, google, understand and stay healthy. The health care system in the US is broken, it’s up to you to take responsibility for yourself. Stop whining.

  51. TheSkaAssassin - College Man says:

    Its only a matter of time until a screw up kills somebody, complain bro.

  52. Foxmom says:

    My grandmother was killed by pharmacy screwups (wrong meds) and my 3 month old went 2 MORE months before getting an effective dose of his reflux meds due to pharmacy screwups(didn’t tell us it had to be refrigerated). SPEAK UP! You cannot tolerate any incorrect information on your medicines. Especially for an infant.