7Investigates: Medication Mix-Ups

A pharmacist fills your prescription but gets it wrong. It’s a simple mistake that can have devastating consequences.

“I don’t know if I’m going to be able to have a child because of this,” said a Wilmington man who spoke to 7News on the condition that his identity is kept confidential.

He was trying to have a baby with his fiancée, so a doctor prescribed him a drug to boost his testosterone and sperm count.

“The next morning, on my way to work, I realized that I was groggy. I didn’t feel right,” he said.

Within days of taking the pills, his side effects worsened. He had headaches, dizziness, trouble sleeping, and even sexual dysfunction.

“The exact outcome that I wanted to have a baby, this medication did the exact opposite,” he said.

He took the drug for a month. When he ordered a refill, the pharmacy realized it made a mistake. He was supposed to be taking clomiphene citrate. Instead, he was given clomipramine, an antidepressant with a slew of nasty side effects.

“He said, ‘I know. We made a mistake. The pharmacist that filled your prescription typed it in wrong, and if you look, it’s only two or three letters off, and they sound exactly the same,’” the man said.

It was only a few letters off, but those few letters wreaked havoc on him.

7News has discovered the Massachusetts Board of Pharmacy investigated more than 200 serious medication errors in the last three years. Records show dozens of prescriptions filled with the wrong dosage or the wrong drug.

More than a decade ago, a pharmacy board report took an in-depth look at two dozen patients who were seriously harmed by a medication mix-up. Many were children. One older patient had to be hospitalized for five days. Another was admitted to the burn unit after their skin started blistering and peeling.

“One death or one serious injury is really one too many,” said Barbara Fain, executive director of the Betsy Lehman Center for Patient Safety.

Like the case in Wilmington, experts say drugs with similar sounding names are often to blame. Patients should make sure their doctor writes the purpose of their medication right on the prescription, write down the name of the medication to make sure it matches what they get from the pharmacy, and call their doctor or pharmacy if they have any unexpected side effects.

“If your instinct is telling you that something may be wrong, you may be right,” Fain said.

The man 7Investigates spoke with just wants pharmacists to take a few extra seconds to double check every prescription.

“The issue with dispatching medication is, it’s a matter of life and death. I was lucky,” he said.

The pharmacy that mistakenly gave him these pills told us these kinds of errors are very rare. But when they do happen, they take action to try to make sure similar mistakes don’t happen again.

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