Prescription mix-ups

Medicine, that's just what Martha Cope thought her eight-year-old daughter, Kaylee needed.

"She was complaining about a soar throat. Her younger sister had strep throat so I took her to the doctor, and they gave her a prescription for an antibiotic," said Martha Cope.

The prescription was for cough syrup. Cope noticed it ran out quickly.

"I was like, 'Mom look at this. It's gone,' and she started reading the directions. It was labeled give Kaylee one and a quarter teaspoon by mouth three times daily. It should've been, give one and a quarter teaspoon once daily for three days," said Cope.

She immediately called the pharmacist, who she says admitted that the dosage on the label was wrong.

"I started freaking. Oh my God. You labeled it wrong," said Cope.
Oklahoma pharmacists fill thousands of prescriptions each day. The wrong prescription is called a mis-fill, and the Oklahoma State Board of Pharmacy says they happen for several reasons.

"Handwriting errors. Transcription errors. A substitution error based upon, again, with a name that's very close. Called in prescriptions. You can misunderstand on the phone," said John Foust, D.Ph., the Executive Director of the Oklahoma State Board of Pharmacy.

Another concern is when prescriptions have similar spellings but very different purposes. For example, we found a water pill that had a name similar to the name of a muscle relaxer.

Foust says there are measures in place to prevent pharmacists from giving out the wrong prescription when the name is similar to that of another medication.

"You'll try to isolate those products. You'll put something between them. You'll put a sign up in front of it that says please check," said Foust.

Plus, there are other measures pharmacies take to prevent mis-fills, like changing the font or lettering for certain medications, and when it comes to giving the wrong dose, like in Kaylee's case, there's a plan to prevent it.

"Many of the recommendations that have come out is for physicians and pharmacists to put the dose only in milliliters and to dose things in milligram per kilogram," said Foust.

Foust also says if the medicine is something you're not used to taking, double check.

"Know the reason the medication is being prescribed for, for example, if the physician were to write for pain, or for infection, or for cough that's a very good way for pharmacists and patients to understand and know what exactly the medication is for," said Foust.

Plus, Foust says always ask the pharmacist if you have any questions about your medication.

Still, even with those safety measures in place, med mix-ups still happen.

When they do, you can file a complaint with the Oklahoma State Board of Pharmacy.

They then investigate and take action when needed.

"Everything from revocation of a license, down to requiring additional continuing education," said Foust.

As for Kaylee, she was sick for almost two weeks, but is doing well now and learning to cope.

"She's still leery on taking Tylenol, and it's very upsetting," said Martha.

From January to late May of this year, Foust says the State Board of Pharmacy received six complaints regarding mis-fills.

He does admit its likely not all of them are reported.