# Question about incorrect filling of a prescription



## lily67 (Jun 14, 2006)

Ladies

Hope that you are both well.  I hope you don't mind, but I have a quick question for you about dispensing a prescription.

As a result of my thyroidectomy, I'm obviously on Levothyroxine for life.

I picked up my last prescription from the GP's dispensary and when I opened it last night, instead of a box of 100mcg Levothyroxine, there was a box of 100mg Losartan Potassium instead.  I double checked on the BNF exactly what this was and as you can imagine was very shocked to read what this is for and what it does.

Now, I checked the label on the box and it said 100mcg Levothyroxine and had been signed in both the Disp and Check boxes by 2 separate people.  However, the packaging on both the Levothyroxine and Losartan is identical, so I can understand that this was a very easy mistake to make.  They are on different shelves in the dispensary (I had a look tonight), but I think that what has happened is that the Losartan was put on the wrong shelf when the shelf was restocked. 

I've complained to my GP and they've completed an incident form, but what concerns me the most is that the manufacturer is putting these drugs in identical packaging and it's a mistake that could happen again.  The good thing about being IF and putting ourselves through this torture is that you become very aware about drugs and double check everything.  I can imagine that someone less knowledgeable might have just started taking them without realising.

Does the buck stop with the GP?  Is there anyone else that I can alert to this potentially disastrous issue with the packaging?

Thanks

L x


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## mazv (Jul 31, 2006)

Hi L,

Glad to hear that GP surgery has taken it seriously and completed an incident form and will investigate the incident and learn from this. If you wanted to alert someone further then the best orgnisation to contact is the National Patient Safety Agency (NPSA). The website will have contact details if you wanted to call or email about this.

Dispensing errors do occur from time to time (human error can never be totally avoided) By the sounds of it the dispensary has systems in place to try and minimise this if they keep the products on different shelves. This would appear to be an unfortunate case of lapse of concentration causing the brain to select what it thinks is the right thing because it looks right and is in the right general location. High volume dispensing is a very pressured environment and it can be difficult to wholly concentrate for hours on end. With the best will in the world lapses can happen and you slip into autopilot where a stage in the checking process can be missed. If you are busy you might think you've read something properly but if the script is correct and the label correct and the box looks correct and at a glance has a large L and the right number on it then the brain will fill in the gaps and tell you it is what you expect it to be. There's some interesting research about that suggests that having 2 or more people checking a process actually builds in error and you may not be as attentive as the expectation is that the other person will pick up any error (anyway I digress  )

In terms of liability then it would rest with the organisation which holds the dispensing licence (if that's the GP surgery then it would be their business). Manufacturer's would not be held liable despite what would appear to be an increased potential risk with similar looking products. The MHRA and NPSA have been trying for a number of years to get manufacturer's to steer away from identical packaging with varied success. It is difficult though as packaging is all very much part of company image and branding so most are reluctant to make large changes within product ranges. There are some changes coming through though and some common errors and high risk products have seen packaging changes made to them to try and overcome these issues.

Very relieved to hear that you checked before taking any medication. A good lesson to all that human error can happen and to always double check yourself before taking anything.

Best wishes
Maz x


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