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Help with Medication Error!

AnonymousUserAAnonymousUser Posts: 49,671
edited 06/11/2012 - 8:37 AM in Back Surgery and Neck Surgery

I'm a new poster, but I've been following these forums for about 3 months, since I found out I needed a laminectomy and spinal fusion.

I'm 1 week post-op and it's been a tough road to recovery (and yes, I expect it to take months to fully feel better), it's like taking 3 steps forward, and 2 steps back.

My husband had to go back to work this week, and I've had to take care of my four kids alone. Fortunately, the older two are 14 and 8, and easy enough to get out the door in the morning. The younger two are 3 1/2 and 5 months, a little harder to handle, particularly the 5 month old. Even though she's heavier than the "weight limit" this soon after surgery, my doctor understands the predicament I'm in and just told me to pick her up as little as possible. I only really have to pick her up in the morning - the rest of the time, I can slide her into my lap (poor thing).

Here's the problem. When I left the hospital, the doctor gave me a prescription for Percocet (25 pills). After a week, I contacted the office for more pain pills because of my fear of having uncontrollable pain after taking care of the baby all day. I don't take the pills during the day, but once my husband gets home, I take two separate doses - one right when he gets home, and one right before bed.

The doctor's office called in a prescription for vicodin to the CVS across from my house, and I picked it up 2 days ago. Because I still had some percocet left over, and because I was desperately trying *not* to take pills every 6 hours, I didn't touch the package until tonight.

The outside of the bottle, and the stapled label both show a 7 day supply and Qty of 30. I opened the bottle and it looked "light", so I took all the pills out and counted them. The pharmacy only provided me with 15 pills - with no notation of a lesser number.

My question is this - what recourse do I have with the pharmacy? I don't make a habit of counting every pill while I'm standing at the pharmacy counter - who does? If the doctor only requested a dosage of 15 pills, then they shouldn't put it on the label as 30, as it's fraudulent for me to sign for something I didn't get.

I know that I'll be calling my doctor's office first thing in the morning to find out what dosage amount they called in. But how do I deal with the pharmacy? I realize that because I took the pills home, they can claim that I hid the other 15 pills.

Help!! I feel like I paid for a prescription that I didn't get.

By the way, this is a great forum, and wonderful information from all of you out there. I hope you can help me!

Thanks :)


  • Hi there!

    Your pharmacy predicament's happened to me in the past and recently with a new pharmacy too. In my experience, they're really good about it and don't question you, or think you 'hid the pills', especially if this is the 1st time you've had them.

    Obviously, if it happened time and time again, they might become suspicious, but definitely not the first time.

    Ask to speak to the 'Chief Pharmacist' and just explain what's happened. My pharmacy's adjoined to the doctor's surgery and I think the Pharmacist was just glad I didn't want to report him to the main doctor, becauase too many mistakes on their part doesn't look good!

    I'm sure it'll be fine, but know exactly how you feel!

    Bye, Val
  • Hi Val,

    Thanks for the quick response! (is Val short for Valerie? That's my 14 yr old's name - I'm rather partial to it :)

    I sure hope I have the same experience that you've had in the past with the pharmacy and they won't give me a hard time! But I do plan on being diligent and following it all the way to the top. I can appreciate an error - but I can't appreciate someone skimming from helpless people! I mean really, how hard is it to count the pills and pocket half of them? I would imagine some people are too gun-shy to make a big huff about it!

    Again, thanks for the response!

    Here's hoping to a pain-free existence in the near-future!

  • in the uk we have initials of the dispenser on the label, he can check with the staff and they should remember dispensing it. a controlled drug has to be signed in and out of the pharmacy so all they need to do is check the total in the controlled drug cupboard. hope this helps
  • Go talk to the pharmacy as soon as possible.

    I do have occasions when I am shorted, but I am not charged for the dispense, as they have to get meds in, to completely fill my script.

    Just be honest with them and try not to be judgmental. Just try to be calm, as you try to sort it out.

  • Hi Meghan

    Good luck with your recovery. Before you go down accusing the pharmacist of doing what you think he did, just stop and think. What if its human error? does happen, we are not machines. What if they had two scripts to fill and one was for 15 and one was for 30 and they simply got it the wrong way round?

    I would take someone with me and go see the pharmacist. I would ask them about it but I would also do so only after there was two people present from them and yourself and your witness. If there was a simple mistake, they will admit it and give you the rest. If it wasnt they will want to take it further too. You then are in the position to take it further as well with your witness, just think about who you take with you. You my walk out with your filled script or you may walk out with a battle on your hands with authorities, and I am not sure if in your current condition you would be really up for that either. I can understand your thinking that perhaps the person that filled your script may have a drug problem or something and has ripped you off. But like I said it maybe a simple error and that to me would be preferable in your condition than a complex legal battle with authorities as you try prove (which will be very hard) a 'respectable' pharmacist has done wrong. Please just stop and think, and good luck with your long recovery ahead....
  • Why so few pain pills from your doctor? When I was discharged from the hospital I was given Oxycotin 20mg, Oxcotin 10Mg (oh and by the way they now make a oxycotin 30mg now) Soma, and Percoset. All meds were 60 count. I take both Oxycotin 1 pill each mg 2x a day, Soma- 1 every 8 hours and percoset 2 every 6 hours and sometimes have I wake up in the middle of the night with pain and take 2. 15 hardly seems enough for a couple of day. For me, while I use mostly percoset 60 pills last me 10 days. Can your doctor not prescribe a higher quantity as you just had a major surgery?

  • Hi Meghan, I tend to agree with Disc-Man. We are all human and subject to human error. We need to remember to assume the best, that makes it less likely for us to ass-u-me in error. My motto is always, hope for the best,prepare for the worst. We need to keep a positive attitude and project that not only for ourselves but others as well.Best of luck, and happy healing.
    God Bless and Keep You, and your precious family,
  • No worries! I won't go charging in like a raging bull in a china shop! I do know we make errors -- afterall, I am a mother -- and I probably make more errors than most LOL!
    And I'm more concerned than I am angry.

    As far as Shannon's question about the pain pills - I'll be honest and say I don't know what they're thinking. I will say however that I've noticed in the past 6 years or so that the doctors in this area have really clamped down on what they will prescribe. There were a few high-attention stings around that time with doctors being arrested and losing their licenses due to over-prescribing medications. The only real way to keep getting refills is to go to the ER repeatedly.

    Unfortunately, I know a few people that would cause doctors to think twice about prescribing anything - those who go in to the ER 5 and 6 times a week claiming this ailment or that just to get more heavy-duty drugs.

    Basically, I've been told that if the drugs prescribed aren't enough, they'll refer me to a pain clinic and we go from there. Heck, I couldn't even get medication for the months leading up to the surgery and I could barely walk, much less do any activities around the house.

  • Well, I did start off with a phone call to the pharmacy, since it will be difficult for me to travel there with a 3 yr old and a 5 month old.

    And of course, I got the tired old line of "well we usually double count controlled substances" - and pretty much accused me of lying. Mind you, I wasn't being accusatory or rude in any way, just trying to find out what happened.

    Pharmacist told me I need to bring the bottle and bag in for her to look at and she'll make a spot decision on whether or not to believe me. Hmmmm. I can see this may be a long day!
  • I had a two level fusion L4-S1 7 wks ago and take norco, soma, and occasionally valium. Are you ok with your pain level? If so You are my Hero!!!! If not, I can't imagine trying to parent two kids at home with an above level pain level, you should take what you need. I am amazed!!!!!!!!!!
  • My understanding of the process of prescribing narcotics is this. I was told that my doctor's office can only "call in" scripts for medications under a certain level. My doctor explained that he was prescriping "only" vicodin for pain because he could call it in and I could pick it up. If he prescribed something with higher narcotic level I would have to personally pick up the script from his office (an hour away) and hand carry it to the pharmacy. I don't know if that is specific state law or not.

    Imdunn - Are you only getting vicodin based on my explaination? I've fortunately never run into your issue, but I can understand your concern. The literature I got from my doctor's office pre-op about pain meds was really specific about keeping track of meds because if you lose them, etc. you are out of luck if your run out before the next scheduled prescription. Hope you get it straightened out without too much turmoil.
  • Meghan,
    It has happened to me once and it was for Ambien. I got 19 pills instead of 30. I am not sure what made me even check when I got home but I did. I called the Pharm. right away and I was told that I must have miscounted, not them. I went back to the Pharm. and spoke with the head guy, showed him the prescription, and asked him if he thought I was abusing the drug or selling it. I was steaming to say the least. I asked what safe guards they had in place to insure pills were not being pocketed. He asked me to leave and I gladly took my business to another place.
    Sorry to rant there but it does happen. You might find some resistance with the Pharm. because you waited so long. Good luck

    Emergency surgery in March of 2006 for spinal infection of L 2 and L 3. During surgery, discovered I had Cauda Equina Syndrome. Spine became unstable after surgery and had 360 fusion with 10 pedicle screws, plates and rods in April of 2007.
  • You guys are great :)

    Yes, the reason I was given vicodin as a refill was because federal law prohibits percocet from being called in.

    I'll be honest -- I wasn't even taking the recommended dosage of the percocet (which was 5-325 MG every 6 hours as needed for pain). 11 days post-surgery, I still have 6 pills of the percocet left (out of 25). After living for more than 17 years with chronic pain in my back, knees and left shoulder - up to and including sciatica in my legs and hips and weakening in my legs, I guess I've just gotten used to living with pain. I'm no hero, I just know it has been near impossible to get pain medication in my area for the last 6 or 7 years - so I live with it - my primary physician will give me an unlimited amount of muscle relaxers, but nothing narcotic. It is what it is and I deal with it as best I can - so I save the "good stuff" for days when I can't handle the pain and all I want to do is curl up under a rock and die. I also live with chronic migraines - which no medication has been able to touch. I still have to take care of my kids or work (when I was working) regardless of how I feel - so may as well do it with the biggest smile I can muster :)

    Anyway - after talking to the pharmacist this morning, I dragged the 3 yr old and 5 month old up to the pharmacy to show them the packaging and the bottle of pills. I must have been too tired at almost 3 am to realize that the pills didn't even look like vicodin -- afterall, it has been 4 years since I last took it (for kidney stones when I was pregnant with my 3rd).

    The pharmacist looks at me and says "we have a bigger problem...this isn't vicodin" - so I'm thinking, okay - it's naproxen or something else -- turns out, the 15 pills were percocet. DUH!! Had I paid any sort of attention, I would have recognized it immediately, and I would have approached this completely differently. So the pharmacist is accusing me of switching out pills. HELLO!!! Why on Earth would I risk losing 15 percocet for 30 vicodin??? So she sends me home, with kids in tow to grab the remainder of the percocet prescribed to me 10 days ago. Let's just say that I still had the 25 pills prescribed to me 10 days ago -- ummm ... after major back surgery how could *anyone* go for 10 days with 4 pills?

    I bring the bottles of percocet and flexeril back up to the pharmacy - nearly keeling over in pain after having to put 2 kids in car seats and walking with a 20lb infant - not a good plan this soon after surgery -- but dangit, I want this resolved!

    She looks at me and says "what do you want me to do about it, there's no way this would have left my pharmacy with the wrong drug". Ummm ... just give me my vicodin and let me go home so I can sit down and pretend I don't hurt to my 3yr old?

    After all is said and done, she gives me the vicodin and the remaining prescription from before - but not without a lot of huffing and puffing and additional statements that there's no way this was an error in her store - and tells me that there will be an investigation and they'll have to call my doctor.

    Well, I already called them, just to let them know of the snafu before I went back up to the pharmacy because I was afraid they wouldn't give me the prescription that was prescribed to me.

    What a cluster! I'm not sure what steps I should take at this point - whether to push it further so that regional knows of these "non-errors" - I mean, what if I had been allergic to percocet and had taken it, not knowing it wasn't vicodin?? I do know that they'll probably put a red flag on my account there -- but to hell with them - I won't be going back to that pharmacy.

    So what do you make of all that? :)

  • more action.Anyone who says that there is any humean being incapable of error has a serious problem. I think you should write very consise notes as to what happened including to whom you spoke. After you have all of this information, you should find out who is in charge at the next level, Its best not to skip levels whenever possible, and send a detailed (similar to your posts but with names dates and time of day, incase you forget the names. Your recipts should help with dates and times in case your memory doesnt)certified letter taking it as far up as necessary to make you feel comfortable. Include copies of any correspondence to the next level.Keep copies of everything you send. The pen is very mighty. This of course after you have your pain back under control and have changed pharmacies.
    I hope you are feeling better soon.
    God Bless and Keep you.
  • I've only had vicodin since my fusion surgery too. I was amazed that that was all my surgeon gave me based on what I have read here that others get. At first I truly think I needed more but it is sufficient most days now - although tonight I think I could use somehting stronger! It is the pits when it is bad and I don't have something stronger to get at it - I'm in my recliner for the night.
  • Yes, I agree - write it all down and send a letter cc'd to as many people as you think should know! If the Pharmacist is going to try to create a stink for you, get in there first and make sure all your bases are covered.

    As Shirley has just said, 'The pen is mightier than the sword' and there has to be a reason she's created this stink for you, making you travel back and forth, in pain, with children - it's ridiculous!

    Sounds to me as if the Pharmacy may have problems ahead!!!!!!!!

    Stick at it!

    Bye, Val
  • Ditto to Mammatia -

    Follow-up with the pharmacy's higher-ups.

    Epxlain, be thorough and detailed. You never know if this has been a recurring problem at this pharmacy or not, but you have to let them know.

    Oh, just a little side-note (take this for what it's worth, it could be nothing, but I'm talking from experience here) - are you sure the rx could not have been swapped out or tampered with at home? Do you lock your rx's in a safe? My neighbor had to lock hers up - between house workers and friends of her kids and 'helpful' fellow neighbors, she had pills stolen from her - nasty business, but then it's not a nice world we live in anymore.
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