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HealthCare & Wellness Breaking the Chains of Addiction. The Last Door Recovery Society
Mature discussion surrounding important health issues and concerns. Alternative therapies, healthcare questions, discussion of community resources, peer support help, group therapy, etc.

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Old 03-12-2013, 10:25 PM   #1
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Pharmacy mistake

Today I received a prescription for Tylenol 2. Upon pickup, I was served by a young looking guy who I assumed was a pharmacy Tech at the most. After paying he started explaining the drugs to me which is weird because usually it's the pharmacist who does that. His instructions were lame (just read to me what was already written on the bottle) and he seemed overall kind of unsure but I wasn't too concerned and was eager to get back to work (I usually just read the package information inserts anyways).

I saw one bottle in his hand said ratio-lenoltec 3. It was weird to me because it said 3 but I was given Tylenol 2. So I asked him if he was sure they were giving me Tylenol 2 and not Tylenol 3. He said uhh yeah it's the same thing, that's just a lower dose. So I said ok and left.

Half way down the block I received a text asking to go for drinks tonight. Then I remembered that I never asked him about alcohol (I always do when I have to take a prescription). So I decide quickly walk back and ask but this time I show the pharmacist my bottle. She says definitely don't drink. But then something must have triggered her memory because as I was walking away again she yelled back at me and said "hey wait, were you prescribed T2 or T3" and I said T2.

She took the prescription back, right away said they gave me the wrong drug and her student gave me the wrong information. She totally admitted their fault and the her pharmacy student's mistake. You could tell she was embarrassed. Anyways, lucky I got that text and went back to ask about the drinks! Also could have been worse. Maybe they screw it up and give me birth control pills instead

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Old 03-12-2013, 10:27 PM   #2
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T3 just means more codeine, just take it and enjoy
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Old 03-12-2013, 10:28 PM   #3
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Name of pharmacy, please and thanks.
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Old 03-12-2013, 10:28 PM   #4
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"Today I received a prescription for Tylenol 2"

...

" were you prescribed T2 or T3" and I said T3."

what?
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Old 03-12-2013, 10:30 PM   #5
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"Today I received a prescription for Tylenol 2"

...

" were you prescribed T2 or T3" and I said T3."

what?
whoops, typo. I meant T2. edited.
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Old 03-12-2013, 10:35 PM   #6
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Name of pharmacy, please and thanks.
Shopper Drug Mart in Yaletown. I always get my drugs there and the pharmacist is usually good and detailed with her explanations. So I definitely got bad vibes from this new kid when he tried to explain the drugs to me. He even had difficulty swiping my visa card lol.

Coworkers told me to final a formal complaint. But I can't be bothered. Lucklily the error was fixed before I took the wrong pills and I get the feeling the pharmacist will take some action with the kid.
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Old 03-12-2013, 10:43 PM   #7
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Terrible!! If you don't mind the walk, Norm at Urban Fare is excellent.
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Old 03-12-2013, 10:50 PM   #8
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^

I can vouch for that. I know him personally and he's a great guy.

However, having worked as a pharmacy tech before, this sort of thing does happen occasionally especially in a busy pharmacy.
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Old 03-12-2013, 10:59 PM   #9
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i'm not really sure how being busy could lead to something like this happening.

not only did they give a completely different drug (Rx said T2 but they filled T3), but when I asked the guy if "ratio-lenoltec 3" was the same as Tylenol 2 he told me yes. scary stuff.
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Old 03-12-2013, 11:24 PM   #10
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Your stories don't make sense.. here you say they filled T3 again. Earlier you said they filled T2.

What the guy said what unacceptable though..
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Old 03-12-2013, 11:46 PM   #11
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Prescription was for T2. Initially they gave me something called ratio-lenoltec 3 (same as T3). I have no idea what the hell ratio-lenoltec is. but I saw the number 3 and that's why I questioned it. He said don't worry it's the same as T2. Went I went back, the pharmacist saw the bottle and immediately swapped the pills.
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Old 03-13-2013, 12:25 AM   #12
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shoulda gave those t3's to me!!
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Old 03-13-2013, 08:09 PM   #13
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Damn, that's very unprofessional and kind of disgusting to be honest. The fact that that kid would take something as important as different types of prescription drugs and not be accurate about it is frightening.
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Old 03-13-2013, 09:50 PM   #14
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shoulda gave those t3's to me!!
Nothing will fix the broken heart I prescribed you!
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Old 03-13-2013, 10:22 PM   #15
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you should definitely complain. you don't want this happening to someone else, especially if they have to take multiple drugs. bad mix of drugs is definitely bad. although, they did corrected the situation for you, the next client may not be so lucky.

she may have had or may not have had a talk with the guy that made the error, don't leave that up to luck. take action and just file a complaint in a nice way the kid needs to learn before a lawsuit is up his ass and may be ruining his career, and someone else's life.
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Old 03-14-2013, 12:00 AM   #16
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i'm not really sure how being busy could lead to something like this happening.

not only did they give a completely different drug (Rx said T2 but they filled T3), but when I asked the guy if "ratio-lenoltec 3" was the same as Tylenol 2 he told me yes. scary stuff.
Its actually very easy to mix the two up. It is rare to see a T2 prescription and if you have ever read a physicians handwriting you will agree that a 2 can look like a 3 or pretty much whatever you want it to be.

The fact that he asked and the person said it was the same is negligence. Although the harm from the swap is negligible, the person should feel free to report the issue to the College of Pharmacists

One issue may not have much repercussion but if this occurs daily or weekly then it indicates a greater issue that must be resolved.
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Old 03-14-2013, 01:25 AM   #17
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Ratio-lenoltec is just a generic version of Tylenol with codeine. Whether it be #2 or #3, the numbers would just correlate with each other.

Nocardia is right in that there are very few prescriptions for Tylenol #2 written. For every 100 Tylenol #3 prescriptions written, there is probably 1 Tylenol #2 prescription written. I'm a community pharmacist, and I will likely go through a bottle of 500 tylenol #3 in 2-3 days, whereas a bottle of 500 Tylenol #2 I may very well not use it all up over an entire year.

So for them to mistake your prescription for a T#3 prescription is not an implausible situation. In the world of pharmacy, yes we are dealing with medications, and although in an ideal world there should be zero mistakes, everyone is human. I will bet that every single community pharmacist has made a mistake at some point in their careers (unless they just got out of school and haven't worked for very long), and it's impossible for anyone to guarantee it'll never happen. Yes, it's potentially dangerous, but your pharmacist who prides themselves on NOT making mistakes is likely also disappointed that something like this happened on her watch. More than anyone, i'm sure she understands the potential implications that a slip-up can have on a patient.

To put it plainly, noone can predict it, but sh*t happens. Your mechanic could mess up your brake job and you could drive off a cliff, a chef could unknowingly plate a dish for you with something sharp that you swallow that rips up your insides, etc etc. I'm not trying to protect that pharmacist since I have no idea who they are, but the most important thing is that she realizes that she did make a mistake. She will be filling out incident reports to send to her head office and things, so going back and telling her that she made a mistake is redundant.

In situations like this, it's important they KNOW that a mistake was made. Which in this case they do. And then, it's important they take responsibility and acknowledge that a mistake was made and correct it. You don't want a pharmacy that denies a mistake was made, or doesn't admit their faults. In this case the pharmacist took responsibility and acknowledged that there was a mistake, so I think that is pretty good of them already.

Where I am deeply concerned is the random technician or assistant or student who was going over the medication with you (i'm assuming it was a new prescription?). The student should not be going over something with you they don't understand, nor should they be answering questions incorrectly (obviously).

In the future, make sure you ask to have the "pharmacist" go over the medication with you, otherwise you're just selling yourself short. It's important to be proactive with your health care, don't be afraid to ask questions, and make sure you're asking the right person of course.

Coles Notes: Pharmacies are busy, mistakes will happen. It's unavoidable. Don't pick a pharmacy expecting them to never make mistakes, pick a pharmacy with staff that take an interest in their patients and take responsibility for their mistakes. Make sure you know who the pharmacists are at your local pharmacy, and make sure it's them talking to you about your meds. If not, ask to have them go over it.
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Old 03-24-2013, 01:27 AM   #18
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At the very least, after fixing the mistake, they should have offered to give you the prescription for free..
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Old 03-24-2013, 01:37 AM   #19
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Free narcotics?
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Old 03-27-2013, 12:37 AM   #20
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^with medications it is indeed sort of weird to give anything of that nature away for free, and it is highly unlikely that would happen.

At the most, they may waive the dispensing fee, but that would be unrelated to the actual drug product itself which should be paid for. The moment the door is opened for the possibility of getting some sort of free drugs, it can get very messy. T3 is a narcotic, but it's cheap. What if the same error were made for a drug that cost $500 but wasn't a narcotic? Too many possible scenarios... But the dispensing fee is always the same regardless, so that'd be easier to waive, if they choose to do that at all.
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Old 03-27-2013, 04:09 PM   #21
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Sounds like you were dealing with a student who wasn't being monitored. what_the? already explained the situation quite well. Also, in reality, the difference between T2's and T3's isn't that huge. If you were able to take T2's, taking T3's wouldn't be a problem at all.

As a side note, you should never take alcohol with any medications containing narcotics. Ever.
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