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Drug Error

Drug Error

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I'm sending this in case some of you have advice. I know there are various professionals among you.

Yesterday my daughter got a refill of her allergy prescription. As she went to take the first dose, she noticed that it didn't look the same as the pills she had been taking. The name of the company printed on the pill was not the same one and the format was completely different. She called the pharmacy, and was told to return it which she did. Turns out her allergy medicine whose name I can't remember begins with Zy... and the drug she was given was Zyprexa, which I know well because Michel took it for a year or so before he died. The pharmicist told her it was good she hadn't taken any of the medicine because it was for depression.

When she got home she did some web research and found that Zyprexa is for major mental illness problems and retroactively she was really scared. She is writing a letter of complaint to the pharmacy, and had called me to ask if this incident should be reported to anyone else. (She wondered if I had had any similar problems in the many years that Michel was receiving multiple medications, but I had not.) She is concerned because she thinks the pharmicist (whom she sees regularly and thinks is quite arrogant) is likely to try to cover up his mistake, and she would like to be sure he doesn't. And also because the community served by this pharmacy is low income, with many residents who have limited English, people who would be much less likely to catch an error than a well-educated politically active person with quite a bit of experience handling meds for her father.

So my question. To whom should this be reported? This was in Chicago, if that makes a difference. The incident certainly strengthens the case against similar names for different drugs.

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The pharmacy confused Zyrtec and Zyprexa. It's good your daughter caught the error before taking any. I am a pharmacy technician who works at an institutional pharmacy, where we fill prescriptions for nursing home residents. Just a couple of weeks ago a nurse returned an order we had filled incorrectly, filling Zyrtec 10mg with Zyprexa 10mg. Similar drug names definitely increase the likelihood of errors being made. While our goal error rate is zero, realistically, we are human. But there is no room for arrogance when an error is made.

If Illinois has a State Board of Pharmacy, contact them. I did a quick search and did find a number for the Complaint Intake Unit of the Illinois Dept. of Professional Regulation. Their number is 312-814-6910. You might also want to contact Pfizer, who makes Zyrtec.

Just a note to everyone - when you refill a regular prescription, if it looks different from what you had before, question it. Even the same-looking pill in a slightly different size is probably a different strength. When you get a new prescription from the doctor, write it down before you hand it over to the pharmacist. Better yet, ask your doctor to make a copy of it for you. When you get the prescription, make sure the medication, strength, and directions match what the doctor ordered. If the drug is a different name, verify with the pharmacist that it is a generic version of the same drug. Look out for yourselves and the person you are caring for.

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