Viewpoint: Memorable misfills of a retail pharmacist

1. Mepergan Fortis/cephalexin: A pharmacist told me this story. She discovered that she had dispensed Mepergan Fortis (meperidine/promethazine, Wyeth) (a powerful narcotic pain reliever) instead of cephalexin 500 mg (an antibiotic). It's easy to see how this error occurred. Both are dark red capsules. She called her husband and told him to go to the customer's house to retrieve the Mepergan Fortis. She cried into the phone to her husband: "GO GET IT! GO GET IT!" Her voice broke as she told me the story.

5. Carbamazepine/theophylline: A local doctor told me that one of his patients was in his office "and he's dying." The doctor proceeded to tell me that we had dispensed carbamazepine (which treats seizures) rather than theophylline (which treats asthma). We had dispensed the drugs in the manufacturer's original container, so the doctor knew the contents from the exposed label. After I listened to the doctor's tirade, I asked, "Are you serious that he's dying?" The doctor said, "No, but he's pretty damned mad. His asthma has been out of control for a week." I finally asked the doctor the question that was uppermost on my mind: "Which pharmacist's name is on the bottle?" It turned out to be my partner's name. I told the doctor that I was not responsible for the error, so he backed off. I found out later that my partner was indeed sued.