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http://www.bbc.co.uk/news/uk-england-nottinghamshire-42735588
FFS. Am I the only person that would (a) check that the name on the box matched the label and (b) read the information sheet and possibly wonder why I'd been prescribed blood pressure medication to help me sleep?
Instead this oaf takes six times the recommended dose, experiences side effects, and then wonders why he doesn't feel well.
I know a mistake was made, but equally since I make mistakes all the bloody time I wouldn't assume that someone else was immune from it.
I think after watching a program about boots pharmacists making mistakes as they are overworked (which it sounds like this guy did) , I would check the medicine that was prescribed to me.
I would call BS on him as someone who just wants his 15 mins....
If I was at the borderline beginning of toxicity I think I'd be getting my arse up the hospital for starters
The fact he took the tablets despite having a "nagging doubt" suggests common sense and this guy are not best of friends.
And I always wonder why sleeping tablets have a warning "may cause drowsiness". I should bloody well hope they do.
FFS. Am I the only person that would (a) check that the name on the box matched the label and (b) read the information sheet and possibly wonder why I’d been prescribed blood pressure medication to help me sleep?
Well this story seems to be about mistakes, and I have to admit to making worse mistakes than not realising the name on the box is different to the name on the label when they're kind of similar like that - it's funny what the brain does (sometimes brand names for drugs are different anyway). I also have to admit I don't read the information sheet every time either.
Instead this oaf takes six times the recommended dose, experiences side effects, and then wonders why he doesn’t feel well.
eh? he took 2 pills, how can that be 6 times the recommended dose? I'm not sure where you're getting the idea he was wondering why he didn't feel well, given he'd apparently called 111 before getting any symptoms.
hmmm, dispensing errors are pretty rare, but if I was the local manager of that Boots, I'd be looking for some-ones balls over a cock up like that.
It's pretty straightforward to stop this happening, (the patient facing pharmacist is a different person to get the drugs from the shelf, and you check dispensed against 'script.)The busier the pharmacist, the more robust the system should be.
Sure, patients should be checking what they've been given, but if English isn't your first language or you can't read well, then it's not unreasonable to assume that the professional that's just served you knows what they're doing.
My chemist is a Boots.
They are constantly on the brink when you go in.
Boots took the place over from another company, as soon as boots took over the change was immediate. In a bad way.
Constant staff turnover with one lady being very candid with me as to why she was leaving and lack of staff was the fundamental reason.
@aracer - if he'd read the leaflet the suggested initial dose is 5mg, and he took three 10mg tablets.
Did you read the article?
Dr Payne said 10mg of amlodipine would be a "fairly standard dose". The patient took two 10mg pills
I do as it’s a work habit but many don’t they just take what they have been given, especially if they’ve been on them a long time.
Nah, 2 drugs with similar names, not to mention I don’t think it’s uncommon to have different names on the box as the label (generic name v brand name etc).
Dr Payne said 10mg of amlodipine would be a “fairly standard dose”. The patient took two 10mg pills
Besides the point, ultimately, since the leaflets inside are pretty clear and organised along the lines of "What is this drug for?", "What does it do?", "Who is it for?" etc etc.
Granted, I don't read the leaflet if I buy a packet of paracetamol but something that's only available directly from a pharmacist? Common sense.
Common sense.
And if you can't read?
I have to pick up a prescription containing 3 different drugs monthly from a Boots which is connected to the surgery. Without fail every time I go there is a problem. This month they couldn't find my drugs at all, although they had a record of dispensing them so I wonder who had them 🙂 Shame as they have some very friendly staff.
It's the way of the world. You make a mistake, i want you sacked and compensation. I make a mistake and I'm only human.
If you're taking pills read the bloody label, the enclosed information sheet. It's your life after all.
Not everyone is educated to the same level. "Just read the label and the information sheet" would be great, unless you are poorly educated, of lower intelligence, struggle with English, have failing eyesight, mental difficulties.
Some people are less likely to question authority figures, e.g. doctors, pharmacists.
Drug names can be very similar to each other.
The whole community pharmacy system is on the edge. Boots are no different to other major chains. Government payments have been reduced, script numbers are increasing and hence there are fewer staff to cope with more scripts.
Given what I hear almost every day about community pharmacy the Boots documentary was a non-story. Things are far, far worse than was shown in that.
My chemist is a Boots.They are constantly on the brink when you go in.
Boots took the place over from another company, as soon as boots took over the change was immediate. In a bad way.
Constant staff turnover with one lady being very candid with me as to why she was leaving and lack of staff was the fundamental reason.
Exactly my family's experiences with Boots taking over the pharmacy in Stokesley.
Why would you read the leaflet of your prescription drugs if you’ve taken them for ages?
Bad error by the pharmacy the patient shouldn’t have put the patient at risk.
Why would you read the leaflet of your prescription drugs if you’ve taken them for ages?
Because medical knowledge changes over time, but you know that surely?
What about patients that can't read?
It would be easy for patients not to spot the error with regular prescriptions - I have to collect prescriptions for my my mum (including Amlodipine funnily enough) and every time the packaging and branding on the various bits and bobs are different so you pay more attention to the sticker than the branding on the box.
It seems in pretty poor form to be be attacking the guy who was given the wrong script. Reading a story like this and congratulating yourself for how clever you'd have been in the same circumstances doesn't seem very helpful. Pharmacist's customers are going to be amongst the most vulnerable people in society - raising the alarm about errors that would result in people who are already unwell being given medication that at least ineffective and at the worst dangerous or even deadly seems pretty public spirited on his part.
My gf's dad was killed twice by prescription errors. Luckily both in situations where emergency medical staff were on hand and he could be revived again- but both extremely dramatic and harrowing experiences non the less.
What Drac says and nickc- I read them from habit from a former job but its the pharmacist error if they do not do their job properly
I am enjoying the OP admonishing someone for not reading properly and then not reading the article properly and then dismissing his error when its pointed out to him
Hoisted by ones own petard
I doubt many people who have been on the medication for several months read the PIL every time they open a new box. Really if there is a change in practice then it would be the pharmacists role to say, “are you aware of X,” or “there are new guidelines about Y” when dispensing it. It would be interesting to know how many people read PILs at all for prescription meds even the first time they get them; not forgetting that he was probably taking this when tired late at night, and if he’s needs them didn’t have his reading glasses to hand (PILs are rarely printed in big text).
Amitryptilene can be supplied in white and blue boxes not that dissimilar to the one he was given in error. It can also come in a handful of other colours so depending if he always uses the same pharmacy or they change their generics suppliers he may be quite used to the boxes changing.
if we could rely on patients as a reliable safety net for prescribing issues we wouldn’t need pharmacists. And it wouldn’t take a specialist degree+preregistration training to be trusted to hand out drugs.
surprising that in a world of IT and barcoded products it’s actually possible for a big chain to make this error - you’d expect the stock control system to require it to be scanned out and flag there was no matching “order” (prescription).
As for the drowsiness on sleeping meds question - Amitryptiline is used as a pain/nerve blocker too where the principle objective is not to knock you out. But also there are other ways of making prescribing errors (imaging the doctor picks the wrong drug, or a handwritten script the pharmacist misreads the scribble, so then your (expecting to be) blood pressure meds make you sleepy)...
<span style="font-size: 12.8px;">surprising that in a world of IT and barcoded products it’s actually possible for a big chain to make this error – you’d expect the stock control system to require it to be scanned out and flag there was no matching “order” (prescription).</span>
It's much more complex than that. Not everything goes out in a complete, barcoded pack. The systems are often old, and different systems are used for the patient records, labelling, stock control. Then a different system for electronic scripts. Then you get hand-written private scripts too.
Potentially it could be done, I agree, but would need a significant investment, I'd guess a few hundred million to develop. It would be the same ballpark costs as replacing CRM/billing at a major telco.
(I'm not a pharmacist but one is sitting opposite me. I'm a (surprise surprise) IT consultant).
How does this bloke sleep at night?
Of course medical changes overtime as do medication notices, not all patients are aware of this which is why he GP do a medicine review and pharmacies are informed by drug alerts for major ones. They then inform the patient of any changes that may effect them.
Also loving the irony of the OP misreading the story.
Beej, 200M - too many IT consultants getting paid way too much to half deliver projects for that price. My team could do it for 1/10th if that without breaking sweat, and probably for 1/100th (and they specialise in medical software and all the extra regulatory hurdles that go with it) I’m aware of some of the issues as I know a pharmacist very well, BUT they are edge cases not the routine drudgery dispensing where mistakes are most likely. Moreover those problems have already been solved in traditional retail, and improved stock control etc brings other savings.
You could be forgiven for looking at the box and thinking - this is just a different brand name for my generic amitriptyline. The wrong sticker giving the wrong dosage was on it too, which would confirm that line of thinking. Can't see you would blame the patient at all in those circumstances.
poly - I kind of agree with you, but know how big IT projects tend to go. It should be possible to do it for a hell off a lot less but somehow it never seems to happen, especially when big companies (both customer and supplier) are involved.
That's a full cost though, not just the development part. Thousands of staff to train, (tens of?) thousands of bits of data to be loaded, setting up the full processes to support and run on a long term basis, mechanisms to load new SKUs in etc...
EDIT - And I know I said "develop", implement is a better word. 1000 sites that need IT hardware and network upgrades too.