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Pharmacist’s Diligence Saves Patient’s Health and Money

Jun 11, 2019

I am a retail pharmacist working in a busy chain pharmacy.  A patient came in and requested a temporary supply of his Crestor 40 mg tablets because he had run out of tablets before he was eligible for a refill through insurance.  I checked his profile and noticed that it had been 1 1/2 months since his last 90 day refill so I asked why he had run out.  He said that his doctor had told him to double up and take 80 mg daily.  This didn’t sound correct, but it was after office hours and the patient was adamant that these were his doctor’s instructions and that he would have to stop his medication if I didn’t dispense to him.  I reluctantly gave him 2 tablets and told him that I would call the doctor in the morning to verify the dose and would get back to him the next day.

I tried to follow up with the doctor in the morning but his office was closed. Office staff was available, but I was told there was no way to reach the doctor.  The person who answered the phone checked the patient’s chart but could find no notation regarding a dose increase to 80 mg.  She didn’t think the dose sounded correct either but she couldn’t do anything to get an answer.


The next morning, I contacted the office again and spoke with a nurse who said that when the patient’s dose was increased from 20 mg to 40 mg a few months prior, he had just picked up a 90 day supply of the 20 mg tablets and wanted to double up on the 20 mg tablets to reach 40 mg.  The doctor prescribed a prescription for the 40 mg tablets for his next refill, which we filled and the patient picked up.

When the patient finished the 20 mg tablets, he should have begun taking a single 40 mg tablet.  However, the patient never noticed the change in size and shape of the tablets and didn’t read the label to note the change in strength.

His first fill of the 40 mg tablets was for 30 days, which went through insurance because of the change in dose.  The second fill was for 90 days, which went through because of the change in a day’s supply.

Because of multiple failures in the system of supplying medication to this patient, he ended up taking twice the maximum daily dose of Crestor for around two months!

Commentary from Contributor

I doubt that any passive changes in labeling would have caught this patient’s attention but patient counseling at the time of pick up could have focused on the change in dose and the “look” of the new tablets.  In the retail environment, it is rare to have this kind of time for each patient and it is impossible when the patient receives his medication through a mail order service.  We need to change the public’s perception of what should happen when a prescription is picked up and encourage retail chains to provide pharmacists with the time to properly counsel patients.  The public should expect that the pharmacist or technician “show and tell” the medication and that picking up medication will take longer than a few minutes.  They should get out of the car, hang up their cell phone, listen and pay attention to what they are picking up. With the advent of electronic medical records, it should  also be possible for the physician to check his chart notes and see the increase from 20 to 40 mg.  The dosing error could have been resolved immediately.

–Jennifer Rushing


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