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Check Your Prescriptions PDF Print E-mail
Written by Kelley Underwood   
Saturday, 20 May 2006
This week we've learned the hard way that everyone makes mistakes. Before you begin taking any new medicine prescribed by your physician you may do well to double check what your pharmacist provides.

On April 6th during a visit to Dr. Austin Nobanaga, the primary physician in the Spinal Cord Injury unit at Drake Center, I let the doctor know that I was frequently experiencing tingling or a "pins and needles" feeling in my feet and legs. While this was not necessarily painful, it was quite annoying. To treat this the doctor prescribed a low dose of Amitriptyline, an anti-depressant drug. However to be therapeutic for depression, , the typical dose would be 50mg or higher. My prescription was for 10mg tablets. Dr. Nobanaga warned me that the pill may cause drowsiness and dry mouth. For this reason he suggested the pill be taken just before going to bed.

On our way home, my wife stopped at the Bigg's Pharmacy and had the prescription filled. That night, just before going to sleep I took my first dose. The next morning during my regular bath administered by my wife, I was barely able to open my eyes. In fact, after the bath I continued to sleep nearly the entire day. I did not achieve any level of alertness until after 8:30 p.m., the time we are supposed to begin preparing for bed. Additionally my mouth was exceptionally dry, the lips sticking to the teeth and my tongue sticking to my mouth.

I took the pill again on the second night with exactly the same results. I made an executive decision to stop taking the medicine and live with the tingling. Nearly a week and a half later I decided to communicate with Dr. Nobanaga about the results hoping another solution could be found for the tingling. Later, after phoning in the symptoms, his nurse called to relay from the Dr. that this should not be happening and that I needed to continue the prescription, saying that perhaps I would get used to it over time.

So, I plugged away taking my daily dose of Amitriptyline. I did seem to get better accustomed to the side effects but I still required 12 to 13 hours of sleep before I could function at any acceptable level. Eventually, on May 22, I ran out of pills and my wife visited the pharmacy for a refill. On May 23, as we prepared for bed, my wife opened the bottle and handed me my pill. I was shocked to see that the pill was a very small blue greenish tablet instead of the rather large pink pill I had been taking. I took the tablet but we made plans to contact the pharmacy the next day.

On May 23, it seemed to me, that for the first time in over a month, the sun came up. In fact, it was a overcast and rainy day but I felt so much better than I had in weeks. I was able to awaken early and put in a full day of work and physical therapy without being drowsy. Honestly, it was the best I felt in I don't know how long.

10mg pillThat evening we called the Bigg's Pharmacy and explained the differences in the pills. The woman who answered, very quickly put the lead pharmacist on the phone and he explained that a mistake had been made. The blue green pills were in fact the 10mg tablet I should have been taking all along. The large pink tablets were instead a 100mg dose, twice the usual dosage for anti-depression and 10 times the prescribed dose.100mg tablet

To the pharmacy's credit, they volunteered to call Dr. Nobanaga the next day to inform him of their mistake and to find out if any other treatment might be necessary short of continuing on the originally prescribed dosage. The call was made and I was contacted by the physician's office to verify how things were going.

Fortunately, in my case, the drug in question did not pose any serious threat to me, though for a month I was miserable. However, as another doctor said to me this week, "You were lucky this was not serious, imagine what could have happened with another medication, it could have been life threatening".

Every day, each of us is capable of making mistakes in our family life, at our jobs or at any place in between. These accidents can happen no matter how committed we are to being safe, alert and attentive. However, rarely will a mistake made at my desk, front of my computer, have the life threatening potential of a mistake made by a pharmacist at his or her desk. Of course there are professions; a commercial airline pilot immediately comes to mind, where mistakes could have life, death and eternal implications. Its just that, I think, we pretty much, or at least I, came to think that pharmacies were extremely reliable. As such, for years I've taken what ever pill shakes out of the bottle after receiving a prescription. Rest assured, this is not how I will approach medicines in the future.

I still have a high level of faith in the Bigg's Pharmacy. I think our family is well known to them since we do not go a week without having several prescriptions refilled there. They have always presented us with accurate information about drug interactions with new medicines. We will continue to get our meds there, however; I will always check and double check the labels against the orders of the doctor. I will be very concerned when there is a size and/or color change in my medicines between refills. I'm sure they will not mind me asking questions after this situation.

Maybe you should be more alert also. Check those pills next time.

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Last Updated ( Tuesday, 23 May 2006 )
 
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