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Absolutely horrified

(51 Posts)
GrandmaJan Sun 10-Nov-19 12:32:39

The subject heading is a bit ott when there are much worse things happening in the world but I was shocked when I went to put my pills into their little compartments this morning. I’m prescribed Tramadol 100mgs (slow release) to take twice a day. I won’t go into the reasons why I need such strong pain relief. Anyway I looked at the new pills I picked up last week to find they are Tramadol 50mgs in a 50mg box but the instructions say they are 100mgs slow release. To make matters worse there should be 56 but there are only 36! I’ll obviously be going to read the riot act tomorrow because this isn’t the first mistake they’ve made. I’m a Nurse Prescriber as well so I’m fully aware of how careful they need to be when checking. Yes it was “checked” twice because there are initials scribbled on the box. Well I’ve got that off my chest, I just needed to share it.

Elegran Sun 10-Nov-19 12:40:40

That IS shocking, GrandmaJan If you hadn't looked you could have taken only one pill and then wondered why your pain had escalated, and if a mistake had been made in your pills, it could hve made in others too.

Tramadol is a drug with a street value - I hope this doesn't mean that someone at the pharmacy is skimming a proportion of the pills to sell on for private gain!

GrandmaJan Sun 10-Nov-19 12:55:20

Elegran I didn’t think to check the other meds I’ve received at the same time. Thank you, I’ll now go and check. Your other comment about someone “skimming a proportion” to sell crossed my mind but didn’t want to sound over dramatic. It has happened in the area where I live. It was a few years ago and a pharmacist was short changing elderly patients pain killers hoping they wouldn’t notice. Fortunately I did.

Jane10 Sun 10-Nov-19 15:20:13

Oh dear. Sounds bad. Let us know how you get on at the pharmacist. Hope you're not suffering as a result.

Liz46 Sun 10-Nov-19 15:38:25

A while ago I collected my usual HRT patches. The pharmacist said that he did not have a full pack and would owe me some. No problem.
When I went to open one, I saw someone else's writing on the outside. Each patch had been labelled with the day it was to be used! I realised someone had returned them to the pharmacy and checked the expiry date. Yes, they were out of date!

ladymuck Sun 10-Nov-19 15:42:58

My daughter once collected her prescription from the chemist, and when she opened it she found they had given her an empty box!

Susan56 Sun 10-Nov-19 15:48:03

GrandmaJan, I worked in pharmacy for many years until my retirement.As well as reading the riot act,you need to make sure they fill in a dispensing/pharmacist error report.These are official forms and really important,also useful to check if it is the same pharmacist/dispenser making the error.These forms will also be checked when the pharmacy is audited.As all dispensed medicines should be checked by a pharmacist before leaving the pharmacy this is a very worrying mistake.

wildswan16 Sun 10-Nov-19 16:04:20

It is always very worrying when mistakes are made. I have great respect for pharmacists, but do wonder if we (the government) are asking too much of them. We are all being told to ask their advice rather than go to a GP surgery - but they have no increase in staff and are expected to concentrate on the public's questions as well as their dispensing duties.

GrandmaJan Sun 10-Nov-19 16:19:14

Susan56 thank you for that information. I’ll make sure a form is filled in, I honestly didn’t know about that and obviously they are unlikely to tell me. It is a worrying mistake and I’ll be hot footing it down to the pharmacy in the morning. I’ll let you all know the outcome.

suziewoozie Sun 10-Nov-19 16:41:37

Yes to what Susan said especially as it’s not the first mistake they’ve made. I’d write a formal letter of complaint so it goes through the formal complaints process - this is really serious

Sillygrandma5GK Sun 10-Nov-19 17:08:24

Message withdrawn at poster's request.

Namsnanny Sun 10-Nov-19 17:18:29

Doc Martin's latest episode isn't far from the truth then?

tiredoldwoman Sun 10-Nov-19 17:26:43

My daughter picked up a prescription for me , gave them my name then the address when asked. She was in a hurry so popped in and left them with me . I had to get my glasses to open the packet and thank goodness that I did - in my fumbling I saw that it wasn't my name on the box ! Something similar but not me ! Scary stuff .

Ellianne Sun 10-Nov-19 17:38:29

Oh yes, I've been given someone else's drugs with a similar name too. I thought it was strange there were more packets than my usual.

Floradora9 Sun 10-Nov-19 18:37:39

I got the wrong insulin it could have killed me .

GrandmaJan Sun 10-Nov-19 20:42:17

It is really scary just how many errors pharmacists make. Just reading your experiences is concerning considering all dispensed medication should be checked twice.

tidyskatemum Sun 10-Nov-19 21:14:55

DH got a delivery from the pharmacy a couple of years ago which they asked him to sign for. It was for morphine - which he’s never had in his life. He sent the delivery driver away with a flea in his ear and told the GP surgery, who seemed remarkably unbothered that controlled drugs were not being managed properly.

suziewoozie Sun 10-Nov-19 22:28:09

It’s really important that if you are at the receiving end of a dispensing mistake that you make a proper formal complaint. The main reason for this is not to punish but to make sure that a review is carried out to make it less likely that the error will be repeated

Luckygirl Sun 10-Nov-19 22:37:39

My OH was dispensed a liquid drug and the dosage on it assumed a much lesser strength of the solution. It also said he should take it every hour, when in fact it should have been 3 x a day! If he had taken the dosage on the label he would have consumed an unimaginably huge dose which would have had very serious effects. Luckily I noticed the mistake.

GrandmaJan Mon 11-Nov-19 11:23:40

Good morning. Well I’ve been to the pharmacy and saw a relief pharmacist as the Pharmacist who is the manager isn’t in until tomorrow. I did ask to see her privately. I showed her the box and asked her if she could see anything wrong, obviously she did but her reaction surprised me. She said “oh I’m sorry I’ll dispense the correct medication”. As she stood up I said just hang on I haven’t finished and went on to discuss the 20 missing tablets and I wanted to know what she was going to do about the errors. She said it would be investigated internally & I’d be told of the outcome. I asked if it was going to be reported to the General Pharmaceutical Council. She was surprised at this and said not at this stage. I told her that if she didn’t I would (have just done this now) and it needed referring to their head office and the Controlled Drug Team as it’s a controlled drug. So we’ll wait and see. I’m so tired today because I was in so much pain last night and didn’t sleep. Thanks for listening and sorry it’s so long winded x

suziewoozie Mon 11-Nov-19 12:12:55

GrandmaJ I really respect what you’ve done and especially when you were in pain. I wish more people made formal complaints rather than just moaning or accepting the brush off. I’d love it if you updated us in due course. Hope you have less pain today

Kerenhappuch Mon 11-Nov-19 12:19:44

Wow, that's bad.

A few months ago I went into my GP surgery to pick up a form to have a blood test from reception. After a lot of flapping around, I was handed some sheets of paper. Fortunately, I glanced at it before leaving, and when I spotted the phrase 'unexplained weight loss' (definitely NOT my problem!) I checked the name and it was nothing like mine.

I just went back and asked for the correct form - probably I should have complained, but I couldn't build up a head of steam about it.

GrandmaJan Mon 11-Nov-19 13:07:31

suziewoozie thank you. I felt I just couldn’t leave it especially as 20 Tramadol appear to have gone astray. I’m not saying it could have been one of the staff who took them but it needs investigating thoroughly by someone not attached to the pharmacy. I have had a response from the Pharmaceutical Council who have allocated someone to undertake an investigation.

Jane10 Mon 11-Nov-19 13:10:17

Well done GrandmaJan! I hope you feel a bit better too.

GrandmaJan Mon 11-Nov-19 15:35:21

Thank you Jane10