How many times have you thought to yourself, I should go home and double-check this medication? when you leave the pharmacy? The dosage, the ingredients, the interactions? Me either. Sure, I read the leaflet they include, how to store it, when to give it, and what signs to look for in case of an allergic reaction. But I’m not second-guessing the pharmacist and checking his work. Well, you should! I’ve learned this the hard way, and not just once, but twice! Shame on me.
When Allison was just six weeks old she had severe reflux and was prescribed Omeprazole by the gastroenterologist. I brought it to one of the major pharmacies by our house to be filled and waited. It was a Friday afternoon and I wanted her to get started as soon as possible because I really wanted some relief for her. When the medication was ready, the technician made some comment to me about being a few days short of the 30 day supply the doctor prescribed since the bottles come prepackaged. We started giving Allison the medication immediately when we got home and through the weekend, but the technician’s voice was in my head. I don’t know if it was the dose we were giving her, the volume in the bottle, or the number of days we were supposed to be administering the medication, but something was not sitting right. It’s Sunday so I email the doctor to double-check that I’m not missing anything. The next day, while I’m laying in the pre-op area waiting for an operation, I get a call from the gastroenterologist to stop the medication immediately because the pharmacist made an error and entered the wrong dosage into the computer and we have been overdosing our daughter.
Fast forward to this week, John was diagnosed with gastroparesis and was put on an antibiotic to try to jumpstart his stomach. The doctor and I discussed John’s allergies, particularly propylene glycol, which is found in some liquid medications. She decided she would put him on pills that could be crushed and put in food to avoid any issues. I picked up John’s medication and clearly on the leaflet provided with the antibiotic it states “patient allergies: propylene glycol”. My mommy gut told me to look this pill up to make sure I wasn’t missing anything because I felt like something wasn’t right, and one of the inactive ingredients in this antibiotic is propylene glycol! I called the pharmacy immediately. I’m still trying to sort out how they missed this and will not be letting this go.
This is two separate instances of two different major pharmacies making potentially life-threatening mistakes. We put so much trust into the system that has been developed to protect us and have become so complacent, myself included, that we don’t bother to check anymore if the system is actually working. It blows my mind that this could happen to us, not once, but twice. It makes me wonder how often this actually happens? I know for a fact we don’t hear about these occurrences because the first thing these pharmacies ask you to do is sign a nondisclosure agreement (which we did not, otherwise I would not be writing about it). I will be making it a point to do more research into this and see if I can do anything to put some change into motion before they hurt or kill someone.