A missing Rx


Two days ago, I was at work happily (not really) checking away. I shouted John Smithson’s name out. No one answered, I repeated myself. There was still no answer. I carried on checking.  Then I realised that a woman had been sat in the waiting area for a very long time. I asked what name she was waiting for. She said John Smith (not his real name) and that she had been waiting for 45 minutes!  I assumed that she was absent when I had called out and that she had now returned or that she had not heard me.

I did not remember checking a prescription for that name so I looked on the computer.  Generally, I forget patient’s names but remember medications they are taking. John Smith had last had his prescription dispensed in November. Then I remembered John Smithson’s prescription. Is there a chance that we had made the fatal mistake of labelling under the wrong name? It happens unfortunately.

The woman was collecting the prescription for her husband. I dug out the prescription and showed her the reverse asking if it was her signature. She said yes, ending the moment of panic. I told her that this was not the prescription she asked for, by possibly breaking patient confidentiality and telling her the name on the prescription and that it was similar. This was wrong. However, I was glad that it was not our mistake. It was the receptionists. She had given her the wrong prescription…

I marched over to reception and spoke to the receptionist explaining that the woman had been given the wrong prescription. The receptionist was in shock. Claiming she had confirmed the address with the woman before she gave it out.  I paused and shrugged my shoulders. I turned over the prescription verifying the credibility of this situation by double-checking if it was his signature. She said it was, as far as she knew. Aware of the growing queue at the pharmacy, I left it for the receptionist to sort out.

I went back to the pharmacy and took delight in telling my staff what had happened. It was not our fault. The woman was quietly waiting for 45 minutes. She would probably still be there if I had not spoken to her!

Then someone turned up asking for John Smithson’s prescription. After confirming the address and drug I handed it to him. My Sherlock Holmes moment was now upon me, I  was very puzzled and even more curious Where was John Smiths prescription and why had the woman signed for John Smithson’s?

At our pharmacy, waiting prescriptions are placed in white baskets. I spotted a white basket in the far corner of the dispensary. Gazing at the basket I walked over slowly, and there, was John Smiths prescription! WHAT THE HELL WAS GOING ON?!?!!? I turned it over and compared the signature to John Smithson’s. They were not identical but similar. During the second round of questioning, the woman had mentioned the signature was his AS FAR AS SHE KNEW!

The woman returned holding a reprint prescription for John Smith. My pharmacy assistant started talking about finding it, I shushed her. I processed the prescription and apologised for it taking an hour and the woman left.

 I decided to shred the original and no one would be none the wiser. That’s before my conscience got the better of me. Telling me I should have been honest with the woman. I decided to apologise to the receptionist. I took that mornings purchase of Galaxy Caramel chocolate over to the receptionist and explained that I had found the prescription. She was a lady about it and was glad that it had been found. She refused the chocolate, but accepted a mutual sense of confusion, as we both pondered on why the woman could not recognise her own signature!

Later I ate my Galaxy bar whilst reflecting on the events. I concluded that 1) Pharmacy is never dull place and 2) chocolate makes you happy….

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6 thoughts on “A missing Rx

  1. I love this little story! Very well written, it kept me engrossed till the end:) Ill have to agree, pharmacy is never a dull place n chocolate always makes me happy!

  2. R eally funny story, typical of things that we have to tackle on a daily basis! It would take alot to prize a Galaxy Caramel out of my hands…. hats off to you for offering it to her, but i bet inside you were hoping she would decline the offer!

  3. What a confusing situation! I’ve been in a similar situation but not as confusing as this one!

    Poor lady, she must have a lot of patience for having to sit and wait for 45 minutes and not ask the usual question: ‘where’s my prescription’?!

  4. Unfortunately not an uncommon situation. I have many similar stories to tell.

    Last week I called for Mr Berlin… No response. I carried on. A young, tall, attractive, very well dressed woman was waiting. Ten minutes later she was still waiting. I asked her which Rx she was waiting for.

    “I vant my fazzer medicines” she said in an obvious German accent.

    I asked his name. “Herr Oberfustdammer, Otto” she replied.

    I asked if he lived in Berlin and was staying at a local hotel. “Oh Ja, Zat is he”.

    Sure enough, the doctor couldn’t get his head round the name and had called the patient Mr Berlin. I checked the details, the signature, the drugs etc and, once I was happy, gave her the medication. All ended well and I moved on to the next waiting impending crisis with a smile on my face.

    All of which neatly gets round the fact that the Rx was signed by a different doctor than was printed on the pad, the name was incorrect, the indications were unlicensed in this country and exemption had been claimed for tax credit at the receptionists instruction and the surgery was closed. But, hey, the patient was happy and they got the correct medication labelled with the right name.

    It was just another one to add to the pile of illegal Rxs that I supplied that day by putting the patients interest first and taking responsibility as the RP . There was no SOP to cover that eventuality.

    Just another day at the coal face!

  5. What a hilarious story! These are the points that make me LOL:
    “My Sherlock Holmes moment was now upon me” and “chocolate makes you happy….”
    It reminds me of those days I spent in community pharmacy wherein everyone (except the pharmacist himself) went all over the place just to look for a missing Rx while the yelling for the Rx’s name was going on and about. When it was found, everyone (well, me at least) felt relieved….
    *Just a silly thought: how easy could the tracking be if every Rx is digitally marked so any lost ones could be detected by sensor within a few seconds lol*

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