The WRONG STUFF: How Being Nice Can KILL You
82 year-old Linda is a very sweet person. She’s kind, gets along with everyone, and doesn’t like to make waves. But unfortunately, being nice almost killed her.
Linda takes a blood thinner medicine to prevent another stroke, and her pills have always been the 5mg tablets, which are a peachy-pink. When I saw her last month at my clinic, her level was too low, the second time in a month, so I increased her dose a bit, having her take an extra half tablet every week.
Her new dose was now one 5ng tablet 4 times weekly and 2.5mg (one-half tablet) 3 times weekly, on Mondays, Wednesdays and Fridays. Writing down her new dose on a card, I explained the plan, updated her prescription directions, then faxed the prescription with her new dose directly to her pharmacy.
Linda had about a week’s worth of medicine left in her bottle, so about a week later she called her pharmacy to request a refill. When she went to the pharmacy to pick up her pills the following week, and opened the bottle she was paying for, something wasn’t right.
She pointed out to the pharmacist right then that her pills were a different color than she usually got. He reassured her that that was normal because that’s what they were supposed to be. They were a different color because her prescription had changed.
She shook her head and explained to him that the only change was supposed to be new directions on hew new prescription label, not new tablets. He disagreed with her, insisting that the doctor’s office had changed the tablet size from her old 5mg tablets to 10mg tablets.
She tried telling him that she had always gotten the 5mg tablets and her doctor would have told her if she was going to change the size of the tablets. She insisted that her doctor had only changed the directions at her last appointment, not her pill size.
The pharmacist again told her no, that wasn’t correct, even pulling out the original prescription faxed to the pharmacy. He showed it to her, emphasizing that, her doctor DID change her to the
10mg tablets, and that is what she should be taking now. At that point she then gave up and went home, and took the 10mg tablets according to the directions on the label.
When I checked Linda’s blood thinner level 2 weeks later, it had skyrocketed to a dangerous level. She was very, very lucky she only took it for 2 weeks, because otherwise she could have bled to death.
How could this happen?
On a Friday morning four weeks ago, a car driving by our clinic hit a patch of black ice and careened into a big power pole barely a block away from us. The collision sheared off the top of the pole, its transformer crashing into the middle of our busy street. Luckily, nobody was seriously injured.
What wasn’t so lucky was what happened to us, the nearest business to the downed power pole. Somehow, the transformer’s crash and burn created a power spike that whipped through our clinic before causing our power to go down completely. Our laptops and desktops survived, but the electronic systems that allow us access to our electronic medical records did not.
Luckily, our clinic’s medical records are all stored off-site in the cloud, and although we couldn’t access them, they were intact. But everything else in our clinic was GONE. The hardest hit of all was our in-house pharmacy, who lost their entire database.
All of our pharmacy’s patient information, insurance information, billing, allergies, and ALL of their prescription records were wiped out. Gone. Forever. They had to purchase a new system and start completely over, re-entering in everything from their paper records. As a pharmacist, I still shudder when I think about it, what they went through, calling it “Pharmageddon”.
The Monday after the big crash, the computer people managed to get one server up and running, so the clinic had some access to our medical records. We prayed it would hold up under the strain of everyone of everyone trying to use it at the same time.
That day was also the day Linda came in for her regular blood thinner check, the day I adjusted her dose of warfarin and faxed the prescription that had 10mg warfarin tablets on it instead of her previous 5mg warfarin ones. I STILL don’t know how it happened, as I didn’t change that part of her records. But somehow it got sent out that way.
Linda tries hard to keep herself safe when taking her medicine. When she picked up her prescription, she did a lot of things exactly right. She checked her pills before leaving the pharmacy, so if she had any questions, the pharmacist was right there to answer them.
When she discovered a discrepancy, Linda pointed it out to the pharmacist and asked for clarification. When he pushed back she stood her ground, insisting that her doctor would have told her if there had been a change in the tablet size.
So, where did things go wrong?
Linda gave up too soon.
If the pharmacist wasn’t going to call her doctor to check whether the tablet size had changed, she should have gone ahead and done it. We would have seen the discrepancy and sent a new prescription to her pharmacy to correct it.
Linda almost died because she was too trusting. And too nice.
That pharmacist was NOT in the right. That prescription SHOULD have never been filled in the first place without clarifying the directions because the dose specified in the prescription stated 2.5mg (0.5 tablet) 3 times a week, (MWF), which would ONLY make sense if the prescription was for 5mg, not 10mg tablets. That discrepancy, plus the fact that all of her previous warfarin prescriptions were for 5mg tablets, should have triggered a call to the doctor’s office by the pharmacy to resolve the issue.
When Linda picked up her prescription and pointed out to the pharmacist that her tablet size was different, he should have double-checked the directions on the original copy of the prescription. He should have noticed the 2.5mg (0.5 tablet) inconsistency in the directions and called the doctor’s office to clarify the strength.
But when Linda insisted that her doctor would have told her if she had changed the tablet size, the pharmacist STILL didn’t call the doctor for verification of the dose. That is the responsibility of the pharmacist.
Unfortunately, Linda let the issue drop, and took it as he had insisted she do. She could easily have bled to death over a preventable mistake.
Don’t let this happen to you or to a loved one!
Whether you use a local pharmacy like Linda or a mail-order pharmacy, please be aware that mistakes can happen.
Don’t let you or a loved one pay the price!
Here are 4 Ways to Help Keep Yourself Safe from Getting the Wrong Pills:
1. Check out every new prescription.
If you use a local pharmacy, always open up your new bottles of pills BEFORE you leave the pharmacy. Once you leave, they can’t take the pills back, and you will have more problems fixing any discrepancies. If you use mail order, always compare the pills in your new bottle with what you are supposed to be taking before putting them away.
2. SPEAK UP!
Don’t assume that your prescriptions are always right. As Linda found out, doctor’s offices can generate prescriptions that don’t make sense, and pharmacists can make mistakes. Speak up, so a mistake can be identified before it harms you or a loved one.
3. Don’t Give Up.
If something doesn’t seem right, don’t back off until you are satisfied with the answer. If Linda had stuck to her guns, she could have avoided getting the very dangerous blood thinner level she developed, by either insisting the pharmacy manger call the doctor’s office or by calling the doctor’s office herself to clarify her medicine’s dose and tablet size.
4. Identify any “mystery” pills.
You don’t have to contact the pharmacy to identify what’s in a particular prescription bottle or pill you find on the floor. Entering any pill’s description including color, shape, and imprinted markings into a Google search will give you photos of the exact pill, helping you identify it.
