A South Sound woman says a pharmacist gave her the wrong prescription. Annemarie Owens say she had an allergic reaction that could have killed her.
The heart medicine was in the same container she was used to. She immediately knew something was wrong.
"I took it and all of a sudden I start getting blisters," Owens said. "I start getting blisters on my mouth and I start turning blue."
Owens says she has allergies to medication and food.
Her husband went back to the Rite Aid Pharmacy in Lacey with the prescription to find out what she had taken. The pharmacy told him the prescription in the bottle was not Toprol; instead it was a seizure medication, Topiramate (Topomax).
Owens and her husband filed complaints with the pharmacy and the Department of Health when the incident happened in January 2018.
"We just don't want this to happen to anyone else," explained John Laine, Owens' husband.
Investigators from Rite Aid and the Washington Pharmacy Quality Assurance Commission found the two medications are in close proximity on pharmacy shelves, the NDC label on the stock bottle was not scanned to print the label, and the wrong medication was counted and put in the bottle.
"In this case we had a patient that was dispensed the wrong medication," said Steve Saxe, the executive director of the Pharmacy Quality Assurance Commission.
According to Saxe, the pharmacist who filled the prescription was disciplined by having a letter placed in his file.
"The pharmacist had no prior complaints on them and in this case they issued what they call a 'notice of correction', which is a letter in the file for the pharmacist that would identify an error was made, it was serious, and was in violation of our rules as well."
Saxe recommends patients take the time to have a consultation with the pharmacist when they pick up their medicine, even if it not a new drug. He says that's another opportunity to spot an error.
Chris Savarese, the director of public relations for Rite Aid told KIRO-7:
"Patient and customer safety is a top priority at Rite Aid. We take all customer matters, including this one very seriously. We have a strong commitment to safety with attention to appropriate education and training for pharmacy associates as well as our continued investment in technology in an effort to ensure that our pharmacies maximize accuracy. As soon as we became aware of this incident, in addition to discussions with the patient, we immediately began an investigation, and have taken appropriate actions based upon our findings."
KIRO-7 found this isn't the first time Toprol and Topiramate (Topomax) have been confused. The error was common enough the Food and Drug Administration put out a warning to health care professionals in 2005. The names are so similar. The Institute for Safe Medication Practices keeps a list of medications that are more likely to be mixed up.
Owens says she and her husband contacted KIRO-7 about the mistake to help warn other people.
"I don't want anyone else getting hurt and I want them to know, people need to check their medicine twice, maybe three times." said Owens.
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