# Pharmacist miscounts medication: honest mistake? **URL:** \ **Category:** Miscellaneous and Personal Stuff I Must Share\ **Created:** [June 28, 2012, 10:53pm UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635 "2012-06-28T22:53:44Z")\ **Posts on this page:** 20\ **Page:** 2
**Author:** ![OtisCampbellWasRight](https://avatars.discourse-cdn.com/v4/letter/o/d78d45/32.png) [@OtisCampbellWasRight](https://boards.straightdope.com/u/OtisCampbellWasRight)\ **Post date:** [June 29, 2012, 7:32pm UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/21 "2012-06-29T19:32:24Z")
Is your pharmacist named Mr. Gower? Did he just receive a disturbing telegram? I’d be careful taking those pills. ---
**Author:** ![chizzuk](https://avatars.discourse-cdn.com/v4/letter/c/e36b37/32.png) [@chizzuk](https://boards.straightdope.com/u/chizzuk)\ **Post date:** [June 29, 2012, 7:51pm UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/22 "2012-06-29T19:51:27Z")
I don’t fill many prescriptions, but I found it amusing to have no trouble at all filling 30 Vicodin and then get the third degree from a CVS pharmacist because I had a prescription for a non-standard amount of azithromycin. Normal pre-manufactured Z-pack is 6 pills, my doc wrote for 11. I had to explain everything the doctor had said before she was satisfied. They had big stacks of Z-packs visible behind the counter and I think having to actually go get the jar of individual pills was annoying. ---
**Author:** ![PlainJain](https://avatars.discourse-cdn.com/v4/letter/p/5daacb/32.png) [@PlainJain](https://boards.straightdope.com/u/PlainJain)\ **Post date:** [June 29, 2012, 8:37pm UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/23 "2012-06-29T20:37:13Z")
> [@Jennshark](#): > > 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). Agreed. The fact that they offered to replace the missing pills so easily sounds like CYA. In my area they have machines that count - small town CVS. ---
**Author:** ![Rigamarole](https://avatars.discourse-cdn.com/v4/letter/r/77aa72/32.png) [@Rigamarole](https://boards.straightdope.com/u/Rigamarole)\ **Post date:** [June 29, 2012, 9:22pm UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/24 "2012-06-29T21:22:30Z")
> [@Ferret\_Herder](#): > > 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! I think you completely misinterpreted the reaction of the second guy in that story. It sounds like, after having everything already fixed, you told him about it, and like any rational person (i.e. man) he’s confused because he’s wondering “so what the fuck do you want _me_ to do about it?” when you were just looking for, I don’t know, sympathy? Empathy? More ass-kissing? Whatever it was that made you re-tell the story to him after all was already said and done. ---
**Author:** ![Waenara](https://avatars.discourse-cdn.com/v4/letter/w/50afbb/32.png) [@Waenara](https://boards.straightdope.com/u/Waenara)\ **Post date:** [June 29, 2012, 9:26pm UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/25 "2012-06-29T21:26:46Z")
That they gave you 14 pills makes me this that the error was mostly likely that they misread the prescription incorrectly as being for a two week supply, and then filling the number of pills for that. So still a mistake, but misreading the prescription rather than miscounting the pills. I used to have a job doing data entry of prescriptions, and the majority of prescriptions had a quantity based on a certain number of days, weeks, or months (so either a few pills, or multiples of 7 or 30). For example, a three month prescription is 3x30, not the actual number of days in those months. Unless it was for methadone maintenance - then it was the exact number of actual days. ---
**Author:** ![smokey78](https://avatars.discourse-cdn.com/v4/letter/s/82dd89/32.png) [@smokey78](https://boards.straightdope.com/u/smokey78)\ **Post date:** [June 30, 2012, 12:26am UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/26 "2012-06-30T00:26:43Z")
> [@](#): > > Normal pre-manufactured Z-pack is 6 pills, my doc wrote for 11. I had to explain everything the doctor had said before she was satisfied. They had big stacks of Z-packs visible behind the counter and I think having to actually go get the jar of individual pills was annoying. I work in an independent pharmacy, and we would have actually broke tablets out of blister z-paks and counted 11. Not sure how chain pharmacies react, did they whine about purchasing individual bottles??? If the miscount happened again, I’d be skeptical. Worse off, the pharmacy might assume the customer was pilfering tablets and lying. Shopping for other pharmacies could be wise, one that looks less busy. It depends if the drugs are in automated count cells or hand counted. Most popular drugs are usually in machines. I’ve seen miscounts here and there on those machines. ---
**Author:** ![WhyNot](https://avatars.discourse-cdn.com/v4/letter/w/c77e96/32.png) [@WhyNot](https://boards.straightdope.com/u/WhyNot)\ **Post date:** [June 30, 2012, 2:27am UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/27 "2012-06-30T02:27:01Z")
> [@grude](#): > > 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:😕 One patient of mine has a pill set up I love: she gets her pills in little cell-o packs for each time of day. So her morning pack is clearly labelled “AM” and has her lisinopril, emeprozole and metoprolol. There’s one marked “NOON” with I forget what and the evening pack is labelled “PM” and has her simvistatin and calcium and low dose aspirin. They come on a long strip, she just tears off the next one and takes everything inside. The only separate medicine is her painkiller, which is an “as needed” scrip. I’ve only ever seen this in the hospital, except for this one lady who has them at home. Guess which of my patients is most compliant with her meds and hasn’t yet mixed them up? Does anyone know what this system is called? I’d like to ask some of my docs if this can be used for other patients who have memory issues, but I don’t know what to ask for. ---
**Author:** ![Ferret\_Herder](https://avatars.discourse-cdn.com/v4/letter/f/e47774/32.png) [@Ferret\_Herder](https://boards.straightdope.com/u/Ferret_Herder)\ **Post date:** [June 30, 2012, 3:08am UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/28 "2012-06-30T03:08:26Z")
> [@Rigamarole](#): > > I think you completely misinterpreted the reaction of the second guy in that story. It sounds like, after having everything already fixed, you told him about it, and like any rational person (i.e. man) he’s confused because he’s wondering “so what the fuck do you want _me_ to do about it?” when you were just looking for, I don’t know, sympathy? Empathy? More ass-kissing? Whatever it was that made you re-tell the story to him after all was already said and done. I had to tell him the story because he had no fucking idea why I was pushing a bottle of pills at him and telling him I was returning these and picking up another, different bottle of pills. He literally did not know why I was giving **him** medication, so I thought “Ok, there’s no documentation on this, that’s fine,” so I explained the situation fairly briefly (something like “I called here this morning because my husband was mistakenly given the wrong medication via a clerical error, for a diagnosis he doesn’t have, due to an error here; I’m returning the wrong medication and want to pick up his real prescription”). His response was more like “wait, why don’t you want some bonus antidepressants, again?” rather than “WTF lady, shut up already so we can wrap this up,” so my head exploded and I explained calmly and simply that my husband was prescribed a blatantly inappropriate medication through their error, and I am **returning it** and want the real medication. And I know what it’s like when someone bitches at/around me about a healthcare-related issue that I did not personally cause, since I work in a medical center. My job typically is to apologize for their inconvenience/distress, and try to see if there is any way I can assist or direct them to someone who can. I’ve had to respectfully carry on with some sympathetic chit-chat with a woman who was fairly delusional (she was telling me detailed stories about the songs she’d written - all spurred by things in the environment around us - that had been stolen from her by unscrupulous music producers) while also directing her to her therapist’s office. I didn’t expect him to react the same way the woman did when I called, but paying attention and then saying maybe “I’ll leave this for my supervisor, here’s your medication, sorry for the inconvenience” would have been just fine. ---
**Author:** ![Waenara](https://avatars.discourse-cdn.com/v4/letter/w/50afbb/32.png) [@Waenara](https://boards.straightdope.com/u/Waenara)\ **Post date:** [June 30, 2012, 3:48am UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/29 "2012-06-30T03:48:01Z")
> [@WhyNot](#): > > They come on a long strip, she just tears off the next one and takes everything inside. The only separate medicine is her painkiller, which is an “as needed” scrip… > > Does anyone know what this system is called? I’d like to ask some of my docs if this can be used for other patients who have memory issues, but I don’t know what to ask for. When I worked in home care last year, we were told they were called “ATC rolls” - I guess since they dispense medications in a strip “around the clock”. However, upon googling I didn’t find any hits with this term - maybe it’s a regional usage or just the term my company used. I googled, and found that they can be called [dose-strip packaging](http://www.camprx.com/pdfs/DoseStripInfo.pdf), [medistrips](http://www.bailey-boushay.org/workfiles/medication_management.pdf), and [pharma paks](http://www.pharmahealthltc.com/services/pharmapak.html). It probably depends on the manufacturer. ---
**Author:** ![WhyNot](https://avatars.discourse-cdn.com/v4/letter/w/c77e96/32.png) [@WhyNot](https://boards.straightdope.com/u/WhyNot)\ **Post date:** [June 30, 2012, 11:18am UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/30 "2012-06-30T11:18:43Z")
> [@Waenara](#): > > When I worked in home care last year, we were told they were called “ATC rolls” - I guess since they dispense medications in a strip “around the clock”. However, upon googling I didn’t find any hits with this term - maybe it’s a regional usage or just the term my company used. > > I googled, and found that they can be called [dose-strip packaging](http://www.camprx.com/pdfs/DoseStripInfo.pdf), [medistrips](http://www.bailey-boushay.org/workfiles/medication_management.pdf), and [pharma paks](http://www.pharmahealthltc.com/services/pharmapak.html). It probably depends on the manufacturer. Oh, awesome! Thank you. My google-fu was weak last night. _hangs head in shame_ ---
**Author:** ![EmAnJ](https://avatars.discourse-cdn.com/v4/letter/e/d2c977/32.png) [@EmAnJ](https://boards.straightdope.com/u/EmAnJ)\ **Post date:** [June 30, 2012, 3:59pm UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/31 "2012-06-30T15:59:55Z")
Thanks for the input and stories! Yeah, I found the situation odd, and I have used this pharmacy from time to time with no issues (it’s just five minutes from work) before. The tech/pharmacist I talked to when I called knew what I was talking about right away, as soon as I said I was short pills. She said 'Yes, I remember counting out 14, come on back and I’ll give you the rest." When I arrived, she mumbled something about counting out the PO number instead of the number of pills…or something like that. Not sure exactly what she was talking about. WhyNot, we have those pharmastrips here - they’re pretty much SOP for the elderly. They seem pretty handy! ---
**Author:** ![BoBettie](https://avatars.discourse-cdn.com/v4/letter/b/4af34b/32.png) [@BoBettie](https://boards.straightdope.com/u/BoBettie)\ **Post date:** [June 30, 2012, 11:25pm UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/32 "2012-06-30T23:25:16Z")
I find it highly suspicious- I worked in retail and hospital pharmacies for a long, long time and controlled substances were ALWAYS double and triple counted. I never saw a pharmacist check a controlled Rx and just look in the bottle and guess- they always, always dumped them out and recounted. I would report it to the pharmacist and probably to the store manager as well. Everyone makes mistakes, yes, but that story sounds like straight up bullshit. If anything, she should have back counted the main bottle that she took the pills out of to see how many remained- she could tell easily if she miscounted or if you were trying to short her. She didn’t and also “knew” she only counted 14?? Very, very weird. ---
**Author:** ![Honest\_Woman](https://avatars.discourse-cdn.com/v4/letter/h/f17d59/32.png) [@Honest\_Woman](https://boards.straightdope.com/u/Honest_Woman)\ **Post date:** [November 10, 2012, 6:34pm UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/33 "2012-11-10T18:34:48Z")
I have never has a problem with my regular meds. The doctor called me in a prescription for some pain meds ( I have lung cancer which is very painful to me). He called me in 40 loratabs and when I got home I had a feeling I should count them. I had only 30 in the bottle. One fourth of them were not there! I called the place I got them at and was told that they were double counted. I counted them 4 times and there were only 30. I have never had this happen to me before. ---
**Author:** ![cochrane](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/cochrane/32/10441_2.png) [@cochrane](https://boards.straightdope.com/u/cochrane)\ **Post date:** [November 10, 2012, 10:59pm UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/34 "2012-11-10T22:59:42Z")
If you have a prescription with 45 or 60 pills in the bottle, how are you going to count the pills at the counter? Open the bottle and pour the pills out right there? Are you going to make the next customer in line wait while you count them out? Doesn’t sound very practical to me. Yes, I know the OP was prescribed 20 pills and you could just open the bottle and notice if you’re short. But many prescriptions can be for far more pills, especially for a 2x per day medication. Eh, didn’t notice this was a zombie. Still, my comment stands. ---
**Author:** ![WhyNot](https://avatars.discourse-cdn.com/v4/letter/w/c77e96/32.png) [@WhyNot](https://boards.straightdope.com/u/WhyNot)\ **Post date:** [November 10, 2012, 11:21pm UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/35 "2012-11-10T23:21:31Z")
> [@cochrane](#): > > If you have a prescription with 45 or 60 pills in the bottle, how are you going to count the pills at the counter? You get a pretty good sense when you’ve gotten the same refill a lot. You won’t be able to eyeball if 5 are missing, but 10 or 20, sure. But yes, count 'em at the counter. Step to one side so someone else can be helped, but count 'em. Most of the painkillers and benzos aren’t often dispensed in more than 30, and you can fit them into the bottle lid and count them back into the bottle. If you have a big bottle of something, then ask them for a tray so you can count them. They have lots of pill counting trays back there. ---
**Author:** ![Czarcasm](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/czarcasm/32/4050_2.png) [@Czarcasm](https://boards.straightdope.com/u/Czarcasm)\ **Post date:** [November 10, 2012, 11:24pm UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/36 "2012-11-10T23:24:03Z")
So this is something that’s just going to happen once in a while, because miscounts are bound to happen. Has anyone ever gotten too _many_ pills, then? ---
**Author:** ![TriPolar](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/tripolar/32/3008_2.png) [@TriPolar](https://boards.straightdope.com/u/TriPolar)\ **Post date:** [November 10, 2012, 11:29pm UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/37 "2012-11-10T23:29:22Z")
I never got too many. Several times one or two short. Luckily I don’t have to take anything important enough to count anymore. Never had a problem going back to get the extra pills. ---
**Author:** ![WhyNot](https://avatars.discourse-cdn.com/v4/letter/w/c77e96/32.png) [@WhyNot](https://boards.straightdope.com/u/WhyNot)\ **Post date:** [November 10, 2012, 11:33pm UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/38 "2012-11-10T23:33:27Z")
> [@Czarcasm](#): > > So this is something that’s just going to happen once in a while, because miscounts are bound to happen. > > Has anyone ever gotten too _many_ pills, then? Only once. Told the tech, and she just shrugged and said she’d be happy to take back the extra, but she’d just have to throw them away, so if I wanted them, I could keep them. I think it was metoprolol or something not-exciting. ---
**Author:** ![don\_t\_ask](https://avatars.discourse-cdn.com/v4/letter/d/e68b1a/32.png) [@don\_t\_ask](https://boards.straightdope.com/u/don_t_ask)\ **Post date:** [November 10, 2012, 11:40pm UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/39 "2012-11-10T23:40:43Z")
Personally, if I were the OP, I’d be more concerned by the fact that I am seeing a doctor who thinks that the appropriate first response to a temporary stressor is a prescription for psychotropic drugs. Unless they are a stop gap for the failure of the other recommended treatments. ---
**Author:** ![Senegoid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/senegoid/32/6606_2.png) [@Senegoid](https://boards.straightdope.com/u/Senegoid)\ **Post date:** [November 11, 2012, 7:54am UTC](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635/40 "2012-11-11T07:54:08Z")
> [@don\_t\_ask](#): > > Personally, if I were the OP, I’d be more concerned by the fact that I am seeing a doctor who thinks that the appropriate first response to a temporary stressor is a prescription for psychotropic drugs. I’d be even _more_ concerned if the OP, terrified of doing some helicopter flying _and_ dosed up on benzos, is actually _flying_ the helicopter! :eek: I’d be even still more concerned if I were the helicopter passenger and the pilot was a zombie! [Previous page](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635.md?page=1) [Next page](https://boards.straightdope.com/t/pharmacist-miscounts-medication-honest-mistake/626635.md?page=3)