Daniel had an earache Monday night, so Brett took him to our regular GP yesterday afternoon - I don't mess around when it comes to ears. He was given a prescription for antibiotics, which is what I expected, which Brett took to Dischem in Norwood to be filled.
He called to tell me that now Daniel's such a big boy, he's got Augmentin tablets, and has to take two big tablets, twice a day. He said he asked the pharmacist if he was really sure that that was what Daniel should be taking - and the guy just referred to the prescription, and said 'yes'. Alarm bells started going off, but I left it until I got home. In the meantime, had a discussion with my (nearly 70 year old) mother - who happens to be on a course of Augmentin too - two big tablets, twice a day. The alarm bells started ringing a little louder.
When I got home, I had a look at the pack of tablets - a pack that I recognise very well, as I have had those very meds before. Me, the adult. I BBM'd my doctor, who said that he may have made a mistake, but that I should definitely go back to Dischem. So I did.
When I got to the counter, I asked the pharmacist if it was correct that that medication had been prescribed for a five year old boy. She looked very alarmed, and then spent 10 very long minutes digging through a messy pile of the afternoon's paperwork to find the prescription.
Turns out that the doctor had indeed prescribed the wrong thing. I asked why the pharmacist hadn't questioned the doctor, as it was very clear to me - the person who is not a pharmacist - that the prescription was wrong. Oh, she says, my colleague checked with your husband. My husband? The writer and publisher? The one who's NOT a pharmacist? (When actually it was him who queried with the pharmacist, not the other way around). When I asked how they could possibly dispense such heavy antibiotics for a five year old boy, she snarkily pointed out that his age is not on the prescription. No, it's not. But it very definitely is on their system, and my child was standing there in front of them - clearly not an adult.
Am I wrong in believing that the pharmacists are the experts in medication here? They are the ones who are supposed to look at the prescription, look at the person for whom it is prescribed, and if there are GLARING errors (like a not-that-sick child standing there, about to be given a heavy adult dose of antibiotic), that they should maybe pick up the phone and question the doctor?
Our doctor did apologise, and when I asked, he explained that the adult dose is four times the paediatric dose. Daniel would have had severe diarrhea if we had given him what was dispensed. The pharmacist would surely know that too?
Our doctor was apologetic, admitted his error, and is a good guy who makes himself totally available to his patients. We will stick with him, but we will make him check any prescriptions twice before we leave his office.
Dischem - with whom we spend a fair amount of money each year - will not see us again.
11 comments:
Is that Dischem Norwood?
They are shocking!!!!
And rude and disinterested and consistent only in what they screw up!
Thanks for posting this. I've had my doubts about Dischem Norwood for a while, but it's good to get these warnings as a new mom. I'll definately check prescriptions better from now on..
Frances
We should never have allowed the big chains to take out the family pharmacy who offered care and advice and knew each family member by name. Their personal interest and counselling was worth the extra rands for filling a prescription.
@Gina - yes, Dischem Norwood. So convenient... but ja, won't be going back. Was v disappointed in Dr Setzer too, but he handled it so differently to the arrogance of the Dischem people.
The manager of Dischem has just called to apologise for the incident, and admitted that his pharmacist should have picked up the phone to question the doctor. That, really, is all that I wanted.
Well done, Kerry, for not just leaving it and moving on. Far too many of us can't be bothered to follow up on this sort of thing, and that's why the incompetents get away with it. Proud of you!
Oh my goodness Kerry - I followed your updates on this with mounting horror. Can't believe the attitude that you had to deal with. I also spend quite a bit of money at Dischem Norwood and will be boycotting in solidarity. Plus, I am unfortunately not the type of person who would notice that sort of mistake, so will stick with pharmacists that I can trust. I'm lucky enough to go to a small family pharmacy for all things medication related and receive the most superlative service. They know me, my child and my husband and always have brilliant advice on possible side effects to look out for even if there Hasn't been a mistake. (The Colony Pharmacy on Jan Smuts in Craighall for those interested. Its in The Colony Shopping Centre, as is my doctor, luckily.)
Gosh. This is a real problem. Being in the profession, a couple of things are immediately obvious. I think this is the sort of scenario where a couple of errors almost caused a catastrophe, the so called "Swiss cheese" model of accident theory.
Firstly, let's look at the script. I stand to be corrected, but I recall that it is obligatory to write the age of the patient clearly on the script unless the patient is an adult.
(I don't write a lot of scripts but when I do, I always put the age of the child down.)
Secondly, I think that the pharmacist should have checked the script with the doctor, especially after Brett queried the drug dose with him. Doctors, like any human being (airline pilots and cricket captains included), make errors. The reasons for these are legion, but the role and responsibility of the pharmacist is to check and query if there is any suspicion that an error has been made. It is difficult for them to do this often because there is a perceived power gap between the pharmacist and the doctor which makes the pharmacist feel that he shouldn't bother the doctor.
The third factor I think is at play here is the fact that the large chain pharmacies have resulted in the demise of the family pharmacist to whom the error would immediately have been obvious (because he would have known you and your children).
I wonder with horror how often this kind of event occurs every day.. At least someone was on the ball.... Well done Brett..
Dischem's email to me:
Dear Kerry
Thank you for taking the time to bring this issue to our attention.
I believe that Herbert Mayer the Dispensary Manager has been in contact with you to apologise for this issue.
Although the Dr`s instructions were followed meticulously, we do acknowledge that more caution should have been taken considering the age of the patient and by changing and confirming the different dosage form with the prescribing Doctor.
This matter has been addressed with the pharmacist concerned and we would like to assure you that we take such matters seriously.
We trust that you will find this response satisfactory and should you require any further assistance please do not hesitate to contact us.
Kind regards
Diana Andre
Dis-Chem Head Office
0800 201 170
And the response from Discovery:
We have received the claim that you are querying about. Our system does not question the doctors decision due to their professional medical experience. If you would like to take this further you can contact the South African Medical Association on: 0124812000.
I wish you a great day further.
If you have any further questions, please call us on 0860 99 88 77 or email healthinfo@discovery.co.za.
Concerned mother
I agree with everything Mikes has said.However I just wanted to point out that this problem is not confined to the Norwood dischem only.On various occassions the dischem at woodmead has behavoured unethically and rude to boot.The syrup antibiotics on two occassions were not mixed adeqautely so that I was two doses short.Inappropraite substitutions have been made.
I have been told that the pharmacist they emply are very junior, just qualified with no experience in retail as the more expereinced pharmacists will not work there due to the Low rates they are paid.This is no excuse!!!!
Nevertheless, As a parent always double check the prescription with what you are dispensed.Check if the reconstituted Volume is at the mark on the bottle, and finally go with yout instinct, question the pharmacist, doctor again if you not comfortable or sure.
we all make mistakes, just sometimes doctors' mistakes may have more severe consequences.
however, this mistake wouldn't have been too serious. an 'overdose' of augmentin would have little or no effect, even on a child. i sometimes purposely give higher doses of he beta lactam type antibiotics in the face of severe sepsis exactly because the higher doses of this class doesn't really carry extra side effects. there are others where it would be catastrophic, so the jist of your post is relevant. these things should be checked and double checked. by all concerned.
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