Scary Medication Mixup

The good news is that my Mom had her follow-up appointment with the eye doctor and her eye is much better. Seems she had an infection in her tear duct but the medication the doctor gave her fixed her right up.

As I said in my earlier post Mom's eye doctor brought her some medication from Fred Meyer pharmacy on Sunday. Unfortunately the pharmacy only had half the pills she needed so she had to go to the store and pick up the rest on Thursday. When she went there they gave her the rest of the antibiotic her doctor prescribed plus a second bottle of pills.

She figured her doctor must have prescribed another medication for her so she read the directions "take 3 at bedtime" and started taking them Thursday night. On Saturday she called me and said she thought the new pills were making her sick and she wasn't going to take any more. She said she couldn't sleep all night after taking them. And by Saturday morning she was feeling really lightheaded and woozy like she might fall down. As the day progressed she started feeling a little better. But I agreed she should not take any more of those new pills and we would ask the doctor about them on Monday.

When I got to Mom's house on Monday I looked at the new bottle of pills. My first thought was "wow they really misspelled her name this time!" Mom's name is easy to misspell, it's an unusual one. Her name is Annetta and the name of the bottle was Arnetta. Her last name begins with an I and has an o in it. So did the different name on the bottle. Something in the back of my head vaguely suggested something wasn't right. Mom always gets her medications from the same pharmacy and they are all computerized, so why would there be a misspelling?

We took the bottle of pills to her doctor's office. He took one look and said "what are these?? I didn't prescribe these!" The pharmacy had mistakenly given my mother someone else's medication!! As the doctor put it we were lucky those pills weren't nitroglycerin or something. But we still didn't know what they were.

We took the pills right back to the pharmacy and my mother got her money back. They apologized profusely. But how scary that could have been. We were so lucky the result was not worse than what happened.

I looked up the pills on the internet. They were Phenytoin or Dilantin, an anticonvulsant used to treat epilepsy. I read under Precautions that "patients with impaired liver function, elderly patients, or those who are gravely ill may show early signs of toxicity" and "Phenytoin may also raise the serum glucose level in diabetic patients" (Mom is diabetic).

From now on Mom will double check the name on any pills she picks up. And I will double check with her especially any time a new medication is needed.