Friday, May 2, 2008

Medication Mix-Up

You hear about stories, you read about them and then you ask..."how can that possible happen?" Well it happened to me, and it's just about the scariest thing I have been through in a long time.

Yesterday I went in for an early dental appointment. I had to have a tooth extracted (the polite way of saying having a tooth pulled). I scheduled it early, so I could have the entire day to play, be mom, do the typical Thursday things I do, and then go off to work in the later afternoon. The extraction went very well. I was told that I should feel very little pain as I had had a root canal a couple years earlier, so there are no nerves. Just in case they prescribed some ibuprofen to reduce swelling and vicodin, to be used only if needed. No biggy. If you know me I am a mediphobic, so I will typically deal with pain unless absolutely necessary.

After my appointment I drove to a well known national store to fill my prescription. While I waited I picked up a cheap, cute little handbag, some kitty chow for a cat we have just adopted at our back door, and a handful of mother and grandmother day cards. When I went to check out I was told that I had a card on file for "express pharmacy" check out. I questioned the guy as I had not been aware we had done that. He showed me the last four digits on the credit, again one i did not recognize. My oldest was sick earlier this year, away at college in Florida, so my assumption was that my husband must have set that up for the convenience of Elliot to fill his prescriptions. So, sweet no payment due off my debit card and away I went. Feeling fine and only smiling half way, as one side of my face was still numb.

The Dr. told me to take the meds within an hour, before the numbness wore off so there would be little or no pain and swelling. So I did. The kids were eating lunch, so I decided to call my husband to see what card this express payment was on. As I was talking to him, trying to figure things out, I started getting very woozy and dizzy. He said this card number was not ours. I then looked at the name on the bottles and it was the wrong name. My husband, in a panic then asks me what I just took. I read the bottle and it was morphine and codeine...on an empty stomach. My husband works in a hospital around doctors. He instructed me to contact my daughter at school to come home right away. I then contacted the pharmacy which realized they had made a "terrible mistake".

My Dr. called, as the pharmacy had contacted them. The Dr. asked if there was anyone who could be with me. I was not to sleep for four hours. I had to be kept awake. My husband then called, after having spoken to one of the docs he works with who said the same thing. I must be kept awake and be monitored. Emily was able to rush home from school, the boys were put down for naps and she could not stop laughing. We don't get much sympathy around here. She said I went to stand up, fell onto the floor and then laid there. She thought I was joking, but then came over and started prodding me to wake up. I thought she had pushed me onto the floor when I awoke, but needless to say it was no easy task to keep her drugged mother awake.

Later a friend came over to watch the boys, so Emily could get Ethan from school, go by the pharmacy to drop off the wrong prescription and pick up the right one. After being awake for almost five hours, I was told I could sleep, but needed to be checked every 15 minutes to make sure I was breathing. Does this not sound like I should have gone to emergency. Later learning because of the doses, and combination I could have slipped into a coma. I slept for about 18 hours. I have little memory of anything. My daughter said she would ask me a question, and I would say nothing, and then ten minutes later slurred out the answer. She still is chuckling. I ended up missing work. Fortunately I had called my boss earlier in the day when this all started.

Oh, how nice. The pharmacy gave me the right prescription for free and the items I purchased earlier had been put onto someone else's credit card. So they reversed the charges and said they would not charge us for those earlier. (Darn, I should have bought those frames I was looking at too)

Almost 24 hours later I am left with a migraine hangover. My husband had to stay home this morning to get Ethan to school. And today he is fuming over this entire incident. Only to learn that had I not had the presence of mind to call my husband about a credit card, I could have been passed out on a floor with a 2 and 4 year old at home. Today he said he would be writing a letter to this company. Later this morning I was sharing this incident with a friend who said she knows some one's mother who died having had the same kind of mix up and from the same pharmacy.

So the question is how did this happen. Everyone who knows me, knows that I have at least 15 pairs of reading glasses around my house, in every purse I own, and in my car. Did I specifically look to check the bottles? No, I glanced at them and saw Tr, barely with my blind eyes, and thought nothing of it. The person who's prescription I got has the same first two letters in his name. With prescriptions having generic names I was not concerned about what was given to me. I am not a pharmacist, nor do I know what generic terms are for what medications. So my bad in not reading and asking questions about what was trusted from the Dr. to the pharmacy.

I feel in many ways that God was watching over me, and I am forever grateful that my husband and I understand our spending habits in that I would question an express pay process. That does not sound like either of us, which is why I questioned it. Which had us both wondering what it might be.

Oh the pain in my mouth. Not there. The pain in my head feels like someone has taken knives and are twisting them through my brain. My husband said that with a strong dose of this combination of narcotics this is a side affect. Word of caution...READ the BOTTLE, and if it's a generic version, understand what it is. I did not ask any question because I know what both meds were that I was to have and I am married to a former alcohol and chemical addiction therapist who knows meds like the back of his hand. So you can say he is more than freaked over this incident. Thanks be to God for having people to help me in a moments notice.


  1. Wow, how scary. Sounds like you are in "good hands"! Hope you feel better quickly. The pharmacy needs to be careful. . . makes you wonder how many other prescriptions or accounts that they have messed up. They could end up with a major lawsuit if something bad ever happened. God surely was watching over you! Your husband sounds like a keeper, too!

  2. That is unbelievable. The outcome could have been so bad. I'm glad you are okay. God was truly protecting you and the little ones.

  3. Every system in health care needs to be checked once and then double or triple checked. Everyone is usually so over worked and stressed that mistakes happen. Sad but true. Our pharmacy always pulls out the med bottle out of the bag and looks at it and explains the name, dose, and common side effects when we pick up the prescription. If every pharmacy did that incidents like what happened to you could be prevented. So glad that you were not seriously over dosed. You should write a letter. Who knows who might be the next victim of their mistakes. Hope you get rid of that migraine and have a fantastic weekend. Drug free.

  4. that is very scary. I am glad you are okay. BTW, where are you working?

  5. Wow, that is one of my worst fears! My family wonders why I double check every pill as it comes out of the bottle against what it says on the front. My issue is that I've been taking the same meds for a year and still have a trust issue. I think I'm a little extreme!!

    So glad you're fine. God was definitely watching out for you. Praying your headache gets better.


  6. Praise God you are okay. I know I will be checking my meds more carefully now also. Take care.

  7. Oh, dear! Thank, God, you're okay! And, thanks for the reminder to check and double check and triple check our meds!

  8. Thank God everything worked out well and you were able to be kept awake for that time. It really sounds like such a scary situation to be in. Reminds us all to check our prescriptions. Take care....hope your head feels better.

  9. Wow Elizabeth, I am so glad that you are okay! I am usually very watchful of any prescriptions but I can imagine myself doing the very same things that you did!

    Hope by now your head is feeling normal!

  10. Wow, that is really awful. I'm glad you are all right!

  11. oh my oh my oh my!!!! that is horrible!!! I'm glad you are o.k. I will ALWAYS check my meds from now on and forever more!!!! I'm so glad everything turned out o.k. codeine AND morphine...just one of those will make a person loopy, but both together!!!! WOW!!! Praise God you are doing good!!!!
    Call me!

  12. O my goodness! Thqat could have turned out so differently! Thank God is right! He had people all along the way to help you. So glad all turned out well. Yes, I would be complaining to the company also. My son takes a lot of extremely potent pain meds and we try to be so careful with them. We keep them in a lock box so no none else can take them by mistake. Scary!

  13. Wow. I am SO glad it turned out ok for you! Sure made me realize I need to read those bottles very carefully! Yikes.


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