Pharmacist miscounts medication: honest mistake?

I went and got a prescription for Ativan today because I’ll be doing some helicopter flying soon for work and I’m terrified. The doc wrote me a prescription for 20 pills, and I filled it at the pharmacy this afternoon. I went and picked it up and once back at work looked in the container - it seemed a bit too few. I counted and there were only 14 pills.

I called the pharmacy right away and ended up talking to the pharmacist who filled my prescription. She said she miscounted - even remembered filling my prescription - and to come over and get the other six pills.

Skeptical me thinks she tried to snag the pills. Could this kind of mistake actually happen?

Pharmacists are not the one who put the pills into the containers, that’s the technician. The pharmacist gives the container a quick visual once-over, recaps it, bags it, does some computer stuff and moves on.

Experienced pharmacists can tell at a glance, the number of pills that are in a container. If it was supposed to be 50 pills but you only got 45, I would give them the benefit of the doubt. When your prescription is supposed to only be 20 and you’re missing six, it’s still an honest mistake, but maybe she needs to slow down.

Sure it could happen. My mom was once given another person’s prescription altogether (similar last name).

If the pharmacist were stealing pills she’d have stolen one or two, not 6 – way too noticeable.

I wouldn’t use that pharmacy anymore, though.

Ok, it must have been the tech I talk to/dealt with then. I dealt directly with the person who handled counting the pills.

(I’m in Canada btw, might work a bit different here wrt the pharmacist)

We’ve had it happen with boring ol’ not fun, not expensive pills so yes, it can happen. The fact that it was a benzo makes me more suspicious than if it had been, say, warfarin, though.

If it were I, I’d count my pills before leaving the counter in the future. If it happens again, you can report her to the store manager and/or licensing board in your state. They’ll investigate.

Yes, I’m going to count before I leave from now on with stuff like this. I was actually worried they woudn’t believe me.

This happened to me twice with a post-op narcotic at the same pharmacy. I called their HQ after the second time then switched stores – I think that once may be an honest mistake, but twice with a controlled substance = incredibly shoddy controls or an intentionally crooked pharmacist or tech (or both).

Now, whenever I pick up an RX, I count it at the counter. Oddly enough, I’ve recently been shorted several times on a Nexium RX :dubious:

Let me echo that being shorted on benzos is suspicious, I’m surprised that they will replace the missing pills without another script. (Suspicious on their part, not yours).

Most of the time pills will get replaced without question unless someone at the pharmacy recognizes you as consistently getting shorted on pills and it would depend on the type of meds.

Behind the counter at a pharmacy is a hectic and chaotic place and everyone pretty much just assumes pills will get miscounted eventually.

Every kind of mistake can and does actually happen. I could not begin to tell you the number of times I’ve had to restart a pill count because someone asked me a question, or was standing next to me talking about other numbers (dosages, phone numbers, all sorts of stuff) or because I just had a brain fart and suddenly wasn’t sure if that made 30 or 35 pills so far. Even with all the times I caught myself and restarted, it would shock me if I hadn’t at some point in ten years not caught myself and sent out a prescription with an inaccurate count. There are supposed to be checks and crosschecks and double checks to make sure that kind of thing gets caught, especially in human medicine and especially with controlled substances like benzos, but some of them still slip through.

I always hate hate hated balancing the controlled substance logs at the end of the month because there was always some kind of discrepancy. Nine times out of ten, it was just that someone had gotten busy and not logged a script they’d filled, but there were other times when the count was just plain off by a few pills. And there was one truly horrific time that someone had sent the right number of pills, but it was the wrong drug. (It was for a dog we euthanized a few days later, and it was swapping one type of pain pills for the other, so the patient wasn’t harmed, but…:eek:)

Yup, my husband once got an antidepressant instead of his hypertension medication (he didn’t take it, but noticed the “new” pill design and double-checked); someone misclicked in the computer at the pharmacy and picked the wrong drug. I called his doctor’s office first to confirm what was called in, then called the pharmacy and you could hear the horror in the voice of the woman I talked to when she saw what happened. Lots of apologies, promise to refill ASAP and review procedures, etc. I was fine with that.

Unfortunately I became less satisfied when I came in later and talked to someone else, whose reaction was, “Wait, so you’re saying you don’t want (wrong drug)?” :smack: It was like he hadn’t even listened; I wasn’t changing my mind about whether my husband should take a doctor-prescribed antidepressant, they screwed up and gave him the completely wrong medication!

Happens a lot in my experience. My parents, who are old and have a lot of pills to take, missed pills from time to time so they started counting the before they left the pharmacy. So, I started counting too and found that it was not uncommon. I don’t remember ever getting too many but I have found undercounts.

Missing 6 pills out of 20 seems suspicious to me and agreeing to replace pills based only on the customer’s word makes me think the undercounts are well known to the pharmacy.

Do pharmacies actually count out medications, or just use the weight to judge if the count is correct? The latter seems like it would be quicker.

There are tons of instances of unethical pharmacists, looking for ways to pad their pockets. Just like there are tons of unethical people in probably every type of occupation.

This was circa 1979-80, but when I worked in a pharmacy, they were counted. We used a flat tray with a collection bin at one end. You’d use a spatula to segregate a group of 5 pills and push them off into the bin. You could count out 40 pills in less than 30 seconds probably. When you had the needed number in the bin, you flipped a lid closed and poured the extra on the tray back into the shelf-stock bottle. The lid then made a funnel to dump the counted pills into the 'scrip bottle. I doubt you could set up and use a scale in twice the time it took to count the pills.

It is more likely they screwed up calculating the needed number of pills than miscounted them. Too many people these days can’t do 14 x 4 in their heads, and if they punch it into the calculator wrong, they never catch it.

Kevbo: That is how pill counting works today still. Manually counted by fives with the spatula and tray exactly as described.

Some of the more popular drugs can now be filled by machine, but the majority are still done by hand.

Yes, it was an honest mistake most likely. If someone were interested in stealing medications, they’d take it straight out of the #500 count bottle they counted your prescription from, not from a small quantity in a bottle that will be checked by the pharmacist. It’s possible that a tech or a pharmacist counted your medication, but if a technician counted it, it’s unlikely the pharmacist counted the medication again. Normally controlled substances are double-counted and the quantity is circled to indicate the double-count, but not always.

Some pharmacies have robotic dispensing machines, others have laser counters, and still others have weight based measurements. But with a quantity that small, it was probably just done using a spatula and a counting tray. I wouldn’t think anything of it, #6 lorazepam is really not something most people attempt diversion of.

It’s more likely that any quantity other than multiples of 30 are likely to be 2 week supplies, not 20 day supplies. I doubt that undercounts are incredibly common, it’s more likely that #6 pills is an infinitely small amount of medication in a pharmacy that does any type of volume. The only medications that are tracked down to the unit are CIIs. Anything else is estimated on inventory to fractions of a full package, and counted out to dispense individually.

There have been multiple pharmacy busts in New Jersey over the last several years, so my RX vigilance is justified (at least to my thinking). Some of the drugs diverted by busted pharamcy staff have been rather low-level – stuff like Tramadol and Tylenol 3 (and my Nexium, apparently :)).

So those robot-machiney things count and dispense only certain drugs? The impression I got from Nurse Jackie was that machines were used to dispense most drugs (You meant that I can’t believe everything I see on TV?)

Being a corporate-mega chain-drugstore pharmacist seems to be a deadly dull job, at least that’s the clear impression our local (un)friendly Rite-Aid pharmacists give. It seems that computerization has replaced some of the more cerebral aspects of the job, at least in corporate stores?

Can I just say that US style counting pills and filling bottles annoyed the hell out of me? It was a revelation to move to a country where pills come in blister cards, counting is not needed as the amount is obvious.

The worst is the invasion of US style dispensing with apparently US trained pharmacists(going by their accents) I had a pharmacist cut up a 10 pill card of generic claritin and put it in a container and label it 10 count! :eek::confused: