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When the Pharmacy Just Can't Get It Right

It’s been over a year since I’ve written. I wish I could say that I haven’t written because it’s been smooth sailing and Hadley’s had no issues. But that wouldn't be true. It’s been a year full of blood draws, dosage changes, growth, mood swings, eating habit changes, sleep pattern changes, more blood draws, and more dosage changes. To be blunt, I’m frustrated. Not with anyone or anything in particular, just with this disease in general. I know that kids' moods, eating, and sleeping change all the time. I’ve been through it with the boys, but their growth and changes came with consistency and without regression. I want Hadley to have consistency and fewer blood draws. So, I’m frustrated.

For anyone who’s keeping track. Hadley is now 5 years old, 3 feet 8 inches tall (84th percentile), and weighs 44 pounds (74th percentile). She currently takes Synthroid 68.5 mcg once daily Monday through Friday and 75 mcg once daily Saturday and Sunday. We see her endocrinologist every three to four months. Each of these visits means a blood draw and usually a dose change. Each dose change means another blood draw to confirm that the change is therapeutic. It can be a lot to keep track of. I am thankful that Hadley’s provider clearly communicates each dose change and confirms that I fully understand how much medicine to give Hadley and when to give it to her.

That leads me to the issue at hand, and the focus of this blog post, which is (and has been for five years now) Hadley’s pharmacy. I won’t name them by name and there’s not one particular person to blame. It’s been five years worth of mistakes made, me getting upset, and then me getting over it. Mistakes such as dispensing more than the prescribed number of doses. Mistakes like refilling the prescription much sooner than needed and billing my insurance company. Mistakes like refilling one dose of the medication when it’s the other dose that we needed. We told Hadley’s provider what was happening at one of our visits and she started making sure to send a message to the pharmacy to “DISREGARD ALL PREVIOUS DOSES AND PRESCRIPTIONS,” when changing her dose. The close-to-work location and the fact that they accept our insurance is what have motivated us to keep using this pharmacy. Until now. I had Hadley’s prescriptions transferred to a different and slightly less convenient location, but the truth is, I am probably not welcome back anyways.

Here’s what happened. After Hadley’s most recent dose change we did a 6-week recheck of her lab values. The dose change was effective and her lab values were back to normal so I requested a refill of the 75mcg dose. At the pharmacy drive-through speaker, I gave Hadley’s name and date of birth and the tech confirmed that her medication was ready. I asked the tech if this was the 75 mcg dose because I knew we had plenty of the 68.5mcg dose. More than enough, (see list of mistakes above) but that’s beside the point. The tech confirmed that it was the 75mcg dose. I paid and drove 25 minutes home. At home, I opened the bag from the pharmacy and discovered that the tech had given me the 68.5 mcg dose, not the 75 mcg dose. I was so incredibly frustrated and angry at that moment. I got back in the car and drove back to the pharmacy and called them on the way. I spoke with the tech who waited on me and let him know that I was very upset. I told him I was on my way back to have the CORRECT dose filled. After a hold, he came back and told me that insurance would not cover the correct dose. Another pharmacy employee got on the phone and my frustration was building. She again told me that insurance would not cover the cost of the medication. I told her that I would pay the full price and sort it out with insurance later. It was important that I get this medication filled, I was completely out. She wanted to investigate further and asked when I had the medication filled last. Doesn’t she have easier access to that information than I do while I’m driving? Nevertheless, I gave her the exact date that the medication was filled and the exact days that the medication was given. As a mother of a child who takes different doses and those doses matter, I commit these things to memory as they happen. At least I tried to give her this information, but she cut me off. My anger was building and she was now the reason. I told her that it was reckless for a pharmacy to give out incorrect doses and that my daughter’s safety was in jeopardy. She defended herself and the pharmacy. I hung up on her.

When I got to the pharmacy, I walked in and went to the pharmacy counter. She was informing the pharmacist that I was accusing them of misdosing my child. Which I was. So I confirmed what she was saying, only louder. I let her know that dispensing the incorrect dose of medication was in fact a misdose. She tried to use the word “miscommunication,” but I did not accept that. I let her, and probably everyone in the pharmacy at that time, that if I was not diligent with my daughter’s medication management, she could be a very sick little girl. She assured me that they have never misdosed her. My frustration level was at its peak now. I told her I have a medicine cabinet full of proof otherwise, and that if she checks her computer and audits my daughter’s account, she will see that I am correct. She retrieved the correct dose and handed it to the other tech. She wanted to continue to argue, but I told her I was done with her so she went to the back of the store where I couldn’t see her. The tech who started this whole mess handed me the correct dosage, but wait, there’s more.

When he tried to pull up whatever he was trying to pull up in the computer so that I could pay for my prescription, something wasn’t right. He called for the female tech and said that she did something wrong with the computer. Yes, you read that correctly, she made yet another mistake. Another mistake, potentially at my daughter’s expense. Granted, this time she may have been flustered due to my less than cordial behavior, but she made another mistake. The female tech wouldn’t come out from the back. When the other tech started to go back to find her, the pharmacist stopped him. He instructed the tech to give me the prescription for free, which he did. I confirmed that the correct dose was in my hands, and I left the pharmacy.

Am I wrong here? Is a medication mistake made at a pharmacy a very big mistake? My dry cleaning wasn’t misplaced, my Amazon delivery wasn’t late. My daughter’s medication dosage which is tedious and unforgiving in her tiny body was INCORRECT! As a nurse myself, I just think that this is a big deal, but maybe I am trying to justify my reaction to the pharmacy’s mistake. As Hadley’s mom, I had to draw the line. Perhaps I should have drawn the line sooner before my frustration level reached its max, but that’s hindsight. Either way, we’ve changed pharmacies and hoping for a better outcome in the future. Thoughts?

With Love,


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