There are a lot of things in life we need to be afraid of, but our pharmacy shouldn’t be one of them. Last week I picked up a prescription for a heart medication. Later, at home, I reached for a glass of water and paused a few seconds before swallowing it.
And in that moment, I realized the capsule in my hand was not my usual medication.
Chemotherapy for breast cancer left me with A-Fib and A-Flutter, a condition that puts me at higher risk for stroke. The medication I take to control it is an orange and white capsule, but the newly filled prescription I almost swallowed was solid orange.
Upon closer inspection, I noticed there were a lot of solid orange capsules in the bottle, and when I dumped all 90 of the prescription count out on my kitchen counter, only 60 were my regular orange and white capsules. The other 30 were solid orange.
When I looked even closer, the orange capsules were physically larger, and the numbers stamped on them indicated a higher milligram than my usual prescription. Instead of the 80mg on my regular orange and white medication, the solid orange ones said 120mg.
My first thoughts were what is the drug in the orange capsule, and how the flip did this happen?
I put the larger orange capsules in a clear plastic baggie and returned them, and the newly filled bottle to HEB, a privately held supermarket chain based in San Antonio, with more than 340 stores in the US and Mexico. The HEB pharmacist didn’t seem at all alarmed or bothered by what I showed her.
“No problem. We’ll just refill it with the proper prescription,” she said. She took everything and disappeared, and in a few minutes she came back and said, “We’ll also give you a gift certificate for your trouble.”
My trouble? Her words flew all over me, but I remained calm.
“How much would the gift certificate be?” I asked.
“So my life is worth $25?”
The pharmacist just stood there and said nothing.
“I have two separate heart conditions I take medication for,” I said. “I don’t know what the orange capsule is, or what it would have done to me. No. I don’t want a gift certificate. I want to know how this happened. Can you look in your computer records and see who filled my prescription?”
“There’s no way to determine that,” she said.
“You mean you can’t see when it was filled and by whom?”
She continued to stare at me and say nothing.
“Don’t you want to know who did this? This is more than a mistake. How could somebody count out 30 capsules that were the wrong milligram, size, and color—plus I don’t even know what drug this is—and then put them in the same bottle along with 60 other capsules that are a different milligram, size, and color? How could they not notice what they’d done? I’d like to see the manager.”
Patrick, the store manager of that San Antonio HEB wasn’t any more helpful or comforting. Inside, his alarm bells must have been going off bigger than Dallas, but outwardly he echoed the pharmacist’s offer of a gift certificate! Grrrr….
By now it was obvious HEB was covering their posteriors, but their lack of concern was almost as bad as the 30 mystery capsules in my prescription bottle. “The person who did this has no business filling prescription medication,” I said. They need to be fired and drug tested. Does HEB drug test their pharmacists and pharmacy employees?”
“I’ll look into it,” the manager said.
“And then what?”
“We can give you a credit on the card you used to pay for them.”
I’m not accusing the pharmacist who filled my prescription of being on drugs, but clearly they weren’t in their right mind, either. It wasn’t one pill that “accidentally” found its way into a bottle of 90. That would have been bad enough, but there were 30. Someone was asleep at the wheel.
Over the years, the incidence of pharmacists and pharmacy technicians with substance abuse addictions has skyrocketed. In 2020, Drug Diversion Digest estimated that at least 148 million doses of drugs such as Hydrocodone and derivatives like Oxycontin, along with Vicodin, Valium, Xanax, and Ativan were “diverted” away from customers, but analysts suspect the actual figure may be much higher.
The theft and use of addicting drugs by pharmacists are leading to prescription errors and deadly mistakes that place us, the unsuspecting public at risk. Is your pharmacist giving you the wrong medication?
Be vigilant. Double-check that the prescription medication you’re about to take is the right medication. Your life could depend on it.
Thankful for your catch, Brenda. And your sharing it.
Worked with a pharmacist at a Garden Center, ca. 1980’s, she was out of rehab, still on tight restrictions. Had many layers to go, to get her license back.
Design job, out-of-state, was invited to a dinner party. To my left a pharmacist, who lost her license. Before desert, she went to the restroom. Afterward, her crazy began. As desert was nearly completed, I was called into the kitchen. Was politely told I would be driving the pharmacist home in her car, another dinner party guest would drive me to my hotel. The complete dinner party an Art Film. Rural Mississippi Delta, client had an airstrip and global business……
Another client, told me of her brother, a pharmacist, and his stories of inept prescriptions…..
My grandfather, chief of staff at a hospital, prison, and a mental facility, railed till red in the face, often, about FDA. Off topic I know. But it informs my world view of FDA.
Whoever put your prescription together seems to have wanted to do the-right-thing, thru a troubled mind. Lacking integrity, intellect, gravitas of their profession. Worse, maybe it was a personality raised in the era of everyone gets a trophy, so you get your prescription, have a nice day, we all win.
Again, good catch…………….glad you shared.
Garden & Be Well, XO T
Thank you Tara for those eye-popping stories. Pharmacists with drug problems are nothing new. I just didn’t give it any thought until my experience last week. The manager of the store said he’d never heard of ANYTHING like this ever happening, but after researching online, and now your stories, I know that’s not true. It’s an industry-wide problem that has me wondering what kind of safeguards they have to prevent this, like drug testing. Thank you, sweet lady! xoxox, Brenda
Brenda, that’s scary and the worse of it nobody seems to care. It seems to me that we live in a society where people don’t care anymore about rendering good service and having good work ethics. I had some problem too with my pharmacy (nothing serious like what happened to you) where they were hoping that I would go away without the issue being addressed but I held on like a dog with a bone. People don’t want to be held accountable for their mistakes. It makes me so angry to see how you were treated as if this was a minor problem. I’ll make sure to check my meds from now on. Thank you for sharing!
I agree with you, Yvonne. Good service, work ethics, and accountability seem to be things that are disappearing from our culture. I’m glad my piece has prompted you to check your prescriptions from now on. That’s what I wanted. xoxox, Brenda
Thank you so much for sharing. You may have saved a life! I’m so glad you were vigilant so that you are ok!!
Thanks for reading, Debbie! We live in scary times. I just didn’t think I had to be in fear of my pharmacy. xoxox, Brenda
It’s good you noticed, Brenda! I googled the description of each capsule and found that at least they were the same medication, but the orange caps were indeed a stronger dose than your usual 80 mg. Not good. It’s appalling that the pharmacy and store were so nonchalant about this. I would call or email the parent company to let them know what happened. Obviously, mistakes happen, but the pharmacist or technician who filled the prescription needs to be made aware of what happened. Any prescription I have has the name or initials of the person on the label of who filled it just in case an error is made. Take your business elsewhere in the future.
Thanks, Ann for Googling. I did the same thing, but it didn’t make me feel any better. I get why the pharmacist and the store manager were so nonplussed, but surely there’s a middle ground of concern they could express to the customer. Since this seems to be a well-known, long-time industry problem, I vacillate back and forth about taking my business elsewhere. A new pharmacy doesn’t mean I’m safe. xoxox, Brenda
That’s terrifying, especially after I read Tara’s comment. It makes sense that pharmacists are not above using the pills they’re handling everyday but it’s scary. Have you heard from this HEB? Xo, Barb
Hi Barb, In addition to what happened to me, there are several comments here that should give us all pause for thought. No, I haven’t heard anything, and it’s been 10 days. I specifically asked that HEB corporate call me, but nothing… Thanks sweet lady! xoxox, Brenda
Love your blog. Went to my local family owned pharmacy. Been a customer 12 years. They said my prescription med has a 3 month waiting list. Ok called my large cancer treatment hospital pharmacy they had it. Tried to get my prescription transferred they refused told me they found one dose. No thank you doctor straightened it out. Why did they med all of sudden show up?? I have lost confidence in them. Thank you. ❤
Awe!!! Thank you, Cathy! A three-month wait list? That’s hard to believe if it’s something that’s prescribed for cancer patients. That’s not good, and I know how you feel about losing confidence in them. Makes you wonder, doesn’t it? Be well. xoxox, Brenda
Well said, Brenda. This happened to me awhile back with my med for anxiety. The pharmacist asked to see me when I picked it up; explained they only had enough of x mg… so half of pills would be twice the mg… be sure to break it half! I said no! Loudly and maybe a few tears in voice… This was long before “Dopesick’ but I knew it was just wrong to give more than the controlled substance prescribed! He removed the bit larger pills and said they’d call when new supply came in. I still use same independent pharmacy; but no auto-fill!
I call each month, remind them of dosage and preferred vendor. Then I open the bottle and inspect before buying. I also have statin and BPmeds, and do the same with them. Thanks for sharing this important message!
Thanks for sharing your story, Joan. It was irresponsible of them to give you a larger dosage of a controlled substance and hope you’re not distracted or don’t forget to break one in half before taking it. Grrrr….. You’re smart to open the bottle and inspect the contents before leaving the pharmacy. Thanks! That’s an idea I’ll take to heart and do the same thing. xoxox, Brenda
Contact your State Board of Pharmacy in Austin. They should know about this. Something similar happened to a colleague of mine; he had breakthrough seizures despite taking what he thought was his meds. When no Dilantin showed up in his blood, he had a physician double check the pill bottle – it was an antibiotic.
!!!! That’s terrifying, Barbara! Thanks for the suggestion. I will contact the State Board of Pharmacy in Austin. Many businesses require that their customers wear a shirt and shoes (No Shirt, No Shoes, No Service), and fast food employees and cooks must wear hairnets. I think pharmacies should have a sign that says All of Our Employees Are Drug Tested Weekly… or monthly…. something! Obviously, this is a huge problem I’d never given any thought to. xoxxo, Brenda
Oh my gawd – totally shocking. Yes do take this further – state board – insurance company. Somebody will listen.
Recently at home I opened up my bottle and thought – pills look different – so immediately called pharmacy – she apologized as she should have mentioned it was a different brand. Usually pharmacy tells me in person if colour/size different – not the same brand.
In hospital they gave my dad the wrong medication and he was knocked out completely – got an emergency call from dr to get there immediately – (at this point they didn’t know what had happened to him) wrong meds can kill.
Oh, Rosemarie! The story about your dad is terrifying! When my first husband was in the hospital, he had his spleen removed, he told me the night nurse I’d hired was taking his meds and she was “out of it.” She would place her chair just inside the door to his hospital room so if anyone tried to come in, it would wake her up. I let her go as soon as he told me that and stayed with him night and day. It was my first experience with hospitals and drugs, and I didn’t trust anyone. Like you, I’ve had the pharmacy tell me why the pills look different. It’s scary when you realize how vulnerable we really are. xoxox, Brenda
So scary that they didn’t care!! I’m thankful that you’re okay!! Yes, being vigilant all the time is important!! I was saying that it’s sad we have to be on guard because you can’t always trust that someone is doing their job. Hugs my friend!!!
Tammy, And I can’t imagine how much you’ve had to be on guard over the years! What a stressful way to live. Love to you! Brenda
Our daughter in law is a pharmacist. She WAS at one of the 2 national chains. It was horrifying to hear her work conditions: the number of hours per shift she was scheduled, the other ‘non-pharmacy’ duties she had to fulfill. And the pressure to ‘upsell’ customers. She was essentially doing piecemeal factory work. Judged and pressured to sell more and more and more. She left the retail side of it, took a reduction in pay and couldn’t be happier. Apparently there is a glut of pharmacists so stores don’t care if their employees become dissatisfied and quit since there are always newly minted pharmacists to fill the position
Oh, Becky! Part of me wants to keep my head buried under the covers, but that’s not my nature! The more we know about an industry, the more red flags are raised like upselling customers. Sounds like the corporation’s bottom line is more important than its customers. I’m happy your daughter-in-law did what was best for her. Thanks for telling us, Brenda
Thank you for this exposé! What a wake-up call. I recently have had a lot of prescriptions for various antibiotics. Since these are not my regular meds, I wouldn’t be able to compare them to anything. This shakes my confidence in what I am given – appropriately so. At least I should be able to google a picture of the pill to compare to. I’ll try that next time.
I don’t mean to shake your confidence, Sheila. Just to increase your awareness, and googling a picture of the pill and/or the numbers on them is a great idea. Be well. xoxox, Brenda
glad you caught it…the label on the prescription bottle even describes the pill. i always read all the literature (?) that is attached to prescriptions…sometimes tmi, but i’ve also returned prescriptions because of contraindications or side effects that i am not comfortable with. the problem often starts with the doctor not knowing the patient well enough or just not knowing, period. and prescribing away. as they do. but that is a conversation for another day. thank you for your post.
Hi Bonnie, I’m allergic to so many drugs and have serious reactions so like you, I always read every page that comes with my prescriptions. Both the label and the literature described the yellow and white capsules I take. There was nothing that indicated anything about the orange capsule. I’ve had bad reactions to meds, even chemotherapy, so even with my regular physicians, I always double check when they start talking about prescribing something new. I’m glad you’re careful as well. Brenda
I cannot imagine this ‘error’ with no culpability!!! I’m furious for you. Hoping you are taking the info to the state board or FDA to demand some kind of investigation.
Good luck, and I usually check my refills but many people blindly put their faith in a pharmacy. Will be more observant!
Thank you, Candace. I’m hyper-aware of the meds I take, prescription and over-the-counter, and always read everything on the label and the paperwork that comes with them. By all accounts, this was my regular prescription. Yes, I’m reporting them to the state board of pharmacies. xoxox, Brenda
First of all I want to acknowledge I’m sorry to hear you have A-Fib A-Flutter from your Chemotherapy. I know you struggled so much during your treatment from what you shared. You are a true survivor on so many levels.
As you were sharing your saga I had the exact same reaction to the response you received at the pharmacy. They should all be fired. To respond the way they did to you they must be on drugs that have disconnected their heads heads from their bodies. To offer you $25.00 certificate must have added fuel to the fire. How can anyone in the world miss the point of what has just transpired. Their error is dangerous and serious. I understand their response they wanted to keep what happened to you very low profile.
I did not know that drug addiction is fairly present in the industry, but no surprise.
I take several meds for my chronic health issues and monthly infusions for my RA and I always pray that my infusion nurse is giving me the right medicine and dose for my weight because I’m a light weight. Check that the med is correct and the mg and check my meds read all product info that comes with the med and go on line to read about all the possible side effects. The bottom line is you can’t be too careful. It’s good you are vigilant.
So sorry you had to deal with this.
Thank you, Katherine. I’m sorry to hear you have chronic health problems that require medication as well. I’ve always been super-sensitive to medications and have had two incidents of “CNS.” Central nervous system shutdown. I understand the liability problems pharmacies have, but that should make them even more vigilant and strict about frequent drug testing of pharmacists and pharmacy employees. From the articles I read, I’m not sure we even want to know how many doctors and anesthesiologists abuse the drugs at their disposal. SCARY! xoxox, Brenda
I hope you switched your prescription elsewhere. I think incidents like yours are what has contributed to the rise in independent pharmacies. I personally don’t have to take any medications, but my husband does and they come through the mail. I am going to relay you experience to him. Think of how many elderly people who can’t see well would never notice. Scary!
Cindy, Until now, I haven’t considered independent pharmacies, but it stands to reason their liability insurance must be through the roof, so they would have to be even more vigilant that a large corporate entity with big bucks and lots of lawyers at their disposal. Thanks for telling me. And yes, older people who can’t see well, don’t remember if they took their meds. I think it’s a problem that most of us will face in our lifetime. xoxox, Brenda
AND I THOUGHT IT WAS JUST DOCTORS WHO HAD HORRIBLE BEDSIDE MANNER……………..
A GIFT CERTIFICATE!!!!!!!!!!!!
I THINK I WOULD HAVE PUNCHED THE PLASTIC BARRIER AND THEIR NOSE!
WHAT IS GOING ON?
NO ONE GIVES A SHIT THAT IS WHAT IS GOING ON!NO PRIDE NO MORALS……….
WE ARE DOOMED!
WOW! I’ve never suspected a pharmacist of doing that sort of thing. Thank you, Brenda, for the eye opener! Seems to be a different world we live in today!