I thought they were the same…

I thought they were the same…

Today a patient came in worried his prescription had been filled with the wrong medication. He had just picked up his refills of a blood pressure medication two days prior and we immediately began researching the situation.

The medication was a small white tablet to be taken one half daily. He opened his bottle and dumped a few in his hand and sure enough some tablets we just a little bigger than others. As a pharmacist when this happens for a moment your stomach seems to turn upside down and your heart starts to beat out of your chest. Our career is based around the oath to “consider the welfare of humanity and relief of suffering my primary concern”. However, panic in these situations never helps.

As the patient had picked up his meds two days prior I asked to see the bottle just to see what med I was looking for. That’s when it was clear, the bottle he handed me had a refilled date 8 months prior and was for a different medication than the patient had stated. He said he sometimes combines like pills together but didn’t realize what he had done. There was the problem he saw that they were just “other small white tables too”, so he mixed them assuming they were the same medication.


In the end what was the takeaway here? One don’t mix pill bottles. If not only for the sake they may be different but now you have two different expiration dates, lot numbers and manufacturers. However, the patient did the right thing when he realized the issue he stopped and asked for help. If he had  Drug ID app: a technology that identifies pills for you, he could have possibly done this from the comfort of his own home. We are glad this all ended well!

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