Correct R/X Labels

Incorrect R/X Label

A few weeks ago I decided to try ordering a refill for my prescriptions online. I ordered the refill from the same pharmacy chain that I always use just the online branch instead of the brick and mortar store.   Because we live in a rural area and it is bit of a pain to make a special trip for refills I thought that I would save myself some travel time and some gas money and just order the refill online and have the medication mailed to me.  I have ordered refills online in the past, but I have always driven to the pharmacy to pick up the refill.

This was the first time I had tried to have the medication refilled and delivered to the house.  The process online was fairly easy and straight-forward.  I just had to input the prescription number and within 7-10 business days I could expect to receive my medication.  I made sure that I had plenty of medication with me and allotted the appropriate amount of time so that I would be sure that I would not run out before the refill came in.    I thought that if this worked out I could save myself some extra running around.

When the medication came in I checked to make sure that I received the correct medication.   I opened each bottle and inspected the pills making sure that they looked exactly like the previously filled prescription.  Everything looked the same so I put the pills away and didn’t think about it again.  

Well it just so happens that I had a rheumatologist appointment coming up so I always check my pill bottles before I go to see if I need any new prescriptions.  My doctor doesn’t like to do refills over the phone so I always make sure I check to see if I am due for a new one.  When I pulled the bottles out of the cupboard I realized somehow, and I really can not figure out how, the online pharmacy mixed up the dosing instructions with the medication.  So that the new bottles instructed me to take my Hydroxychoroquine (Plaquinil) 8 tablets once per week on Wednesday when the actual dosage should have been once daily.  And my Methotrexate  label said  to take one tablet daily when it should have been 8 tablets once weekly on Wednesday.

Because these particular medications I have been taking for years I know that I should not follow the dosing instructions that are listed on the new prescription bottles. So I showed the bottles to my rheumatologist this morning at my scheduled appointment.  Because it was an online issue, I had tried to go to the site to report the problem when I realized it last night.  Unfortunately the link that the online pharmacy shows to click to report a problem does not work.  So I asked my rheumatologist what the next step should be.

She called the number listed on the prescription bottle and reported the problem.  By the time I arrived home from my appointment, there was a message from the online pharmacy asking my to please call.  

I called the number left on my machine.  The woman I spoke to apologized and told me that they had started investigating how this could have happened.  The ball got dropped on this particular issue, not once but twice. Apparently, the prescription is filled by a pharmacy technician and then it is checked by a pharmacist. The woman from the online pharmacy apologized profusely. She told me that they would be sending me a $25.00 gift card for my troubles and that I should expect a call from a supervisor.

I appreciate the apology.  I really do.  What concerns me is what could have happened if I had not been so familiar with these prescriptions and not known that the dosing instructions listed on the refills were very wrong. When I asked what the possible ramifications could have been if I had actually taken 8 plaquenil at once, I was told that it could have caused retinal damage that is irreversible.

From now on I plan on checking not only the pills inside the prescription bottle to make sure that they are correct and that the count is correct, but I will be checking the labels carefully to make sure that the dosing instructions are exactly as my doctor has prescribed.