Painful Prescriptions: Dangerous consequences when pharmacists get it wrong

Painful Prescriptions: Dangerous consequences when pharmacists get it wrong
© FOX19 photo of document obtained from Ohio's pharmacy board
© FOX19 photo of document obtained from Ohio's pharmacy board

LOVELAND, OH (FOX 19) - Sitting at her kitchen table, Margaret Link recalls those strange months when she just didn't act like herself.

"I would fall asleep at my desk," she said.

She also remembers walking out in front of a car after work only to be rescued by her sister.

There was also her son's out-of-town hockey weekend, much of which she spent sleeping in the hotel room. As soon as they checked-in, "I immediately went to bed and told him to go hang-out with the other parents and kids. And I just slept all the way until the next morning."

Then one day, she showed-up at her pharmacy looking to re-fill her prescription for the allergy drug Claritin. This was back when doctors had to prescribe it.

"And they looked-up my name and said that they didn't have me on Claritin," Link recalled. "I said, 'Well, that's what I've been taking.'"

She called her son at home to get the prescription number off the bottle.

"And they told me, 'That's not what we've been filling…We've got you on a pill for your nerves, honey.'"

People at the pharmacy told her that someone misread her doctor's prescription. Written in cursive, they told Link the "C" and "L" in Claritin looked like a large "A." So they prescribed her Ativan, an anti-anxiety medication, the "nerve pill" they were talking about.

"I immediately started thinking about what had happened over the last few months for as long as they had been filling the prescription wrongly," Link said. "And it started to become very clear to me why some of my behavior was different and why some of the things had happened."

Link is far from the only person in our area who's gotten the wrong prescription.

FOX19 obtained documents from the Ohio State Board of Pharmacy showing the dangers, too. Although the board could not tell us how many times patients in Ohio have been given the wrong prescriptions, we did obtain documents showing some of the cases in recent years in which it's happened.

Among the most startling:

A West Chester pharmacist received a prescription in June 2010 for the sleep aid Ambien but gave the patient Glimepiride instead, according to a settlement agreement FOX19 News obtained. Glimepiride is a diabetes drug. Three months after getting the wrong prescription, the patient died.

Another West Chester pharmacist, Ohio State Board of Pharmacy Records show, received a prescription for 120 tablets of morphine sulfate in April 2010 but gave the patient 360 tablets of methadone, the drug used to wean people off of heroin. The settlement agreement with the pharmacist shows the "patient was subsequently harmed." But it doesn't say how badly the person was injured.

These settlement agreements with the Ohio State Board of Pharmacy also reveal the punishments the pharmacists received.

The pharmacist in the case of the patient who died was fined $300 and ordered to complete ten hours of continuing pharmacy education.

In the other West Chester case where the patient was injured, the pharmacist was fined $250 and ordered to complete five hours of continuing education.

"They have to make sure that they fill the prescription with the medication that they're supposed to fill it with," said attorney Don Moore, who helped Margaret Link with her case. "Sometimes they make mistakes. Pills look alike. And if they put the wrong pill in for the wrong person, the results could be annoying or catastrophic."

FOX19 News reached out to the Ohio Pharmacists Association for its reaction to our findings.

Executive Director Ernie Boyd said it's highly unusual for a pharmacist to misread a physician's handwriting because usually they recognize the writing style of the doctors in their area.

Boyd also told us it's not necessarily safer for prescriptions to be sent electronically. He recently dealt with a case where the person inputting the amount of drug to be dispensed was incorrect – a mistake discovered by the pharmacy, he pointed out.


UPDATE: A couple of viewers have asked FOX19 News why Margaret Link didn't read the label of the bottle containing the prescription pills. She did. However, the pharmacy did not use the brand name Ativan on the bottle. Instead, the pharmacy used the scientific name lorazepam, which looks very similar to Claritin's scientific name, loratadine, Link says.

More on lorazepam and loratadine.

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