A Texas woman recently was given ulcer medication instead of the prenatal vitamins which her doctor had ordered. The ulcer medication had been prescribed for a woman with a similar name.
After taking the ulcer medication, she began to experience severe pain and went to the emergency room. There she learned that she had a miscarriage.
One of the comments in the article mentioned the hectic pace and nature of pharmacy work. Pharmacists do have a busy work day, and unfortunately are frequently interrupted while doing work which requires a high degree of attention to detail.
Nonetheless, every pharmacy has procedures and checks in place which, if followed, should prevent this kind of error from occurring. Misfilled medications are “never events” which means that there is no acceptable excuse for their occurrence.