Medication Errors Hit Home

My 18 month old daughter had an ear infection. After a brief office visit with the pediatrician we left with a scrip for Omnicef. Off to the pharmacy. In this case I won't mention the pharmacy chain--I'll refer to the pharmacy as "Wrong Aid" to protect their identity.

After dropping the scrip off we did the obligatory 10 - 15 minutes of shopping with the unhappy child until the antibiotic was ready. When I got the bill it was twice what it normally was. The first alarm went off: this is different that the same scrip last month.

I asked a pharmacist who happened to be standing near the register (looking disinterested) about the difference in price. I was still working on the issue in my head. The dialogue (with unspoken thoughts):

Me: This is twice the cost it was last time. (I think something is wrong!)

Pharmacist: The co-pay is set by the insurance company. We have no control over that. (I got a Pharm.D to deal with these whiners?)

Me: But isn't that a big change? Has the concentration changed or something? (I still think there is something wrong.)

Pharmacist: (sigh) Let me look at it. No, it is right. Twice a day. There is enough in there for 6 days. (It is amazing that I don't dip into the Percocets because of these stupid customers.)

Me: 6 days? Isn't that a bit odd?

Pharmacist: That is what the doctor prescribed. There is enough in the bottle for that. 60ml. (Vicodin, Oxycontin...these needy parents of sick babies are driving me crazy.)

At this point I realized that the pharmacist was disinterested--and likely wrong. I decided to cut my losses and do what any self-respecting parent would do in this case: go to the Internet.

Sure enough it was more than double the manufacturer's recommended dose. The pharmacist who filled the prescription entered "twice" instead of "once per day." Interestingly that was a simple mistake and one which doesn't anger me nearly as much as the disinterested slug who could have caught the error. How?

1. When a flag is raised investigate why. My questions raised the flag--even though it was about cost--not dose.
2. The flag should have uncovered two points 1) Why treat an ear infection for 6 days? He obviously didn't pay attention during therapeutics class in pharmacy school and 2) 60ml is the EXACT amount for 10 ml/day for 6 days. Most liquid medications provide a bit extra since the dose pouring into a cup or oral syringe isn't the most exact. The correct dose (5ml/day for 10 days) would have left 10 ml extra.

"Wrong" Aid still calls me to apologize. Their risk management company called. I tell them all the same thing. The original pharmacist made a mistake. That happens. The second pharmacist blew me off and didn't care. That is unconscionable.