Should You Question a Change in Appearance of Your Pills?

Dennis Miller, R.Ph. is a retired chain store pharmacist. His book, The Shocking Truth About Pharmacy: A Pharmacist Reveals All the Disturbing Secrets, can be downloaded in its entirety at Amazon for 99 cents.

Have You Noticed a Change in Appearance of Your Pills?

When refilling your prescriptions, do you have a responsibility to question a change in the appearance of your pills? Are you guilty of “contributory negligence” for failure to do so in the event of a pharmacy mistake?

Do your pharmacists and technicians often appear to be very stressed, with long lines of impatient customers at the pharmacy counter and drive-thru window? The reality today is that pharmacies are very often extremely busy and dangerously understaffed. Is this a recipe for a pharmacy mistake that could harm you?

When you get your prescriptions refilled, have you ever encountered a situation in which the pills you receive look different from what you’re accustomed to getting? For example, the size of the pills, their shape or the color may be different from what you’ve received in the past.

Generic drugs can look completely different from their brand name counterparts and from other generic versions

Even though generic drugs must contain the same active ingredient as the brand name version, the inactive ingredients (binders, fillers, etc.) can be different. In addition, the color, size, and shape of the generic are usually dissimilar to the brand name version.

This leads to a common scenario at the pharmacy in which patients/customers receive pills when refilling their prescriptions that do not look anything like the previous pills that they have received.

Should you question the pharmacist?

Should you ask the pharmacist why the appearance has changed from previous refills? Or should you just assume that the pharmacy is now using a different manufacturer for the pills?

Are you reflexively told “It’s a generic from a different company”?

Have you ever asked about a change in appearance and been told reflexively “It’s a generic made by a different company”? Does the pharmacist or tech reflexively give you that answer? Or does he or she take your question seriously by taking the time to examine the pills?

If you call from home, have you been told reflexively “It’s the same thing from a different manufacturer” without being encouraged to bring the pills back to the pharmacy so the pharmacist can visually inspect the pills?

Is it a mistake?

Is it reasonable to wonder whether the pharmacy has actually made a mistake? (They do.)Should you use an online pill identifier to resolve your uncertainty? Or should you Google the numbers and letters on your pills to see if those pills are indeed a generic version of what you’re supposed to get?

Do you have a responsibility to question a change in appearance?

Do you have any responsibility to ask your pharmacist or tech about the change in appearance? Or should you think, “These are highly trained people who must surely know what they’re doing”?

Lawsuit in Alabama Regarding Change in Appearance of Pills

If a pharmacist is sued, can he/she or his/her employer claim that you have a corresponding responsibility to question a change in appearance of your pills?

In a federal court in Alabama, a pharmacist claimed that a patient/customer had a corresponding responsibility to question the change in appearance. However, the court refused to dismiss this case in which the pharmacy asserted the patient’s contributory negligence as a defense against the error.

It seems reasonable to conclude that the pharmacist bears most of the responsibility for the mistake. It also seems reasonable to conclude that it is often improper for the pharmacist to try to shift some of the blame to the patient/customer for not questioning the change in appearance of the pills. But there may be exceptions.

Situations in which the pharmacist might more reasonably claim that the customer contributed to the error

It is easy to imagine instances in which pharmacists could more reasonably claim that customers were negligent by not questioning a very flagrant pharmacy mistake.

For example, in a busy pharmacy with dozens of prescriptions in the process of being filled, it is not rare that one of John Smith’s medications ends up in Bob Johnson’s bag by mistake. Is Bob Johnson contributing to the pharmacist’s negligence by not reading the pharmacy label, taking the pills, and not questioning the fact that John Smith’s name is on one of the medication vials in Bob Johnson’s bag?

Or imagine a more flagrant scenario. The patient/customer is refilling his Prozac capsules. The label on the refill from the pharmacy says “Prozac” but there’s some kind of syrup in a 6-ounce pharmacy bottle. Surely the customer would have a much greater responsibility to question what appears to be a blatant pharmacy error, i.e., there’s some unknown liquid medication rather than the expected Prozac capsules.

Dispensing the Wrong Drug Is the Most Common Type of Pharmacy Lawsuit

Pharmacy mistakes include the pharmacist dispensing the wrong drug, the wrong dose, the wrong directions, and overlooking significant drug interactions or contraindications (like penicillin or sulfa allergy).

According to David Brushwood, a pharmacist, lawyer, and expert on pharmacy law,

“A ‘wrong-drug’ error in order processing is the most frequent type of pharmacy malpractice lawsuit.”

Brushwood says,

“In some circumstances, a patient’s failure to recognize a wrong-drug error can be a defense to a pharmacy malpractice case based on what is legally referred to as “contributory negligence.” (David Brushwood, “Court limits patient responsibility to detect pharmacy inaccuracy,” Pharmacy Today, Volume 29, Issue 12, December 2023).

Brushwood summarizes the facts of the case:

The patient had received both carvedilol and hydralazine from the defendant pharmacy for many years. His lawsuit alleged that on one occasion, a refill of his carvedilol was incorrectly processed with hydralazine. He checked the label and saw that the information on the label was correct. He did not contact the pharmacy because he “trusted [the pharmacy] to give him the correct pills and he felt no need to verify what he had been given.”

He explained that “when he saw the pill had changed shape and color, he thought it was another generic kind of pill because they change colors, they change shapes.” He did not contact the pharmacy to verify that the contents of his medication vial were correct.

The patient alleged that he “felt dizzy and lightheaded, his chest began hurting, his heart was beating fast, and his blood pressure was above 200.” He was transported to the hospital, and he was treated for the effects of a hydralazine overdose. His lawsuit alleged that the pharmacy had negligently placed 50 mg hydralazine tablets in a vial labeled as 6.25 mg carvedilol.

The defendant pharmacy moved for dismissal of the case, contending that “because [the patient] knew there were risks associated with taking these medications incorrectly, he was contributorily negligent when he took the pills without trying to verify the medication was correct.”

Brushwood writes that the pharmacy’s motion to dismiss the case was denied. He recommends these takeaways:

• Pharmacists cannot rely on patients to detect and rectify dispensing errors. Order processing accuracy is a pharmacy responsibility.
• Patients should be encouraged to ask their pharmacist if they have any questions about their medications, and all questions should be taken seriously.
• If the appearance of a dosage form changes when a continuing supply is provided to a patient, such as a refill with a different generic product, then the patient should be informed of the change.

While checking prescriptions filled by techs, pharmacists should assume there’s an error

I once worked with a very careful and conscientious pharmacist. He told me that when he checks the work done by technicians, he always assumes that there is an error and it is his job to find that error before the medication is dispensed. That level of worry may sound like paranoia, but I think it is a good perspective for pharmacists to have. In my opinion, this is the kind of pharmacist you want to fill your prescriptions.

Watching pharmacists and techs close-up can be a scary experience

You’ve heard the axiom “You don’t want to watch sausage being made.” An analogous observation is that you may be scared if you watch pharmacists and techs close-up as they fill prescriptions at amazingly fast speeds. You may be forever skeptical about the accuracy of pharmacies.

The pharmacy department is like a high-speed assembly line or a video game

When pharmacists or techs lose concentration for even a split second, a catastrophe can easily occur and the customer can end up with the wrong drug, the wrong strength, the wrong directions, or serious drug interactions or contraindications (like penicillin or sulfa allergy) can be overlooked.

When the pharmacist is the last person standing between the patient and the grave

I once read a commentary by a pharmacy professor who admonished students to pay close attention in class and study hard, not simply so they can pass the next exam. He said students need to take their education seriously so that they will become competent pharmacists when they are the last person standing between a patient and the grave.

The Business Model for Chain Drug Stores Is Understaffing

Chain store corporate management sees understaffing as the path to profits. Many pharmacists feel that chain store corporate management prefers to understaff pharmacies because this forces all pharmacy employees to work in overdrive for their entire shift.

Don’t assume that chain store pharmacies are adequately staffed because they fear pharmacy mistakes and the resultant lawsuits. Many pharmacists feel that chain store corporate management finds it more profitable to pay settlements for the inevitable pharmacy mistakes rather than staff the pharmacies adequately so that mistakes are a rarity rather than a common occurrence.

Bottom line: Don’t assume your prescriptions have been filled correctly

Don’t assume that today’s very busy pharmacies are always accurate in filling prescriptions. Examine the pills and the directions on the label carefully, make sure the label has your name on it, and question anything else that doesn’t look right. Pharmacy mistakes occur far more frequently than the public realizes.

Please note:

This article is not intended to give legal advice. In the event of a serious pharmacy mistake regarding a change in appearance in your pills, your responsibility for failing to have questioned that change in appearance may vary depending on the specific details and circumstances.

Dennis Miller, R.Ph. is a retired chain store pharmacist. His book, The Shocking Truth About Pharmacy: A Pharmacist Reveals All the Disturbing Secrets, can be downloaded in its entirety at Amazon for 99 cents.