Dealing with Prescription Mistakes at the MTF

Dealing with Prescription Mistakes at the MTF |

TL;DR: the base pharmacy almost dosed my 4 year old wrong and didn’t even care.

It all started with a fever…

This morning, Dustin and I spent 3 1/2 hours at the base hospital. The whole thing was one ridiculous fiasco after another. Dustin woke up with a 102+ fever and was miserable. He couldn’t even talk. I called to get him an appointment. The first available was in 1 hour. We got there early only to find the doctor we were scheduled to see was not there. At all. Then there was confusion because some thought he was. Others said he wasn’t. Finally they found another doctor that was available.

They decided Dustin almost definitely has strep. They took a swap. Because he met 4 of the 5 criteria, they wanted to go ahead and start him on an antibiotic. It’s a dual antibiotic and one of the two has the tendency to cause diarrhea, so the doctor was prescribing him the lowest effective dose and would adjust the meds if the swab came back as resistant. So to the pharmacy we went.

It went wrong at the Hospital Pharmacy…

After waiting over 45 minutes, we were called to a window to pick up the Rx. The woman at the window said the pharmacist indicated it was a high dose and likely to cause diarrhea and I should follow up with the doctor if it caused problems. I told her that didn’t sound right. During our visit in family medicine the doctor had said he was prescribing the lowest effective does to attempt to avoid diarrhea. She said it is a low dosage medication, it’s just a high dose. She insisted I was wrong and that I was misunderstanding her. I repeated myself three times, each time clarifying more why the dosage did not make sense. She finally brought a pharmacist to the window who repeated the same thing, again talking to me like I was unintelligent and a bit slow in the head. I repeated myself, my concerns and the explanation for by concerns two more times to both women.

Finally the pharmacist, with an exasperated tone and a big sigh, asked if I would like them to call the doctor to verify the dose. I said yes, that’s all I’m asking because this doesn’t sound correct. She huffed at me, told me to wait and they’d be with me after they talked to the doctor. About 20 minutes later I’m called back up to the window. I was right. The dosage had been entered incorrectly. No apology. No indication who was at fault. She then didn’t review the dosage procedures, confirm my son’s weight, review side effects or provide any information other than “the medication can be refrigerated.”
I took the meds and left.

It got worse at Patient Relations…

On my way out, I stopped at the information desk to ask if there was someone I could speak with about what just transpired. I was sent to patient relations. I clearly explained what happened and my concerns that the pharmacy staff was more interested in getting people out of there than dispensing correct medication doses. I made it clear that was unacceptable, especially when dealing with doses for small children where one mL matters. I also pointed out how terrible the effects could have been if dealing with a more potent medication. The response I got from the patient relations staff was that when I “calmed down” I could fill out an ice report online. The Navy Hospital equivalent of a customer comment card. That’s it.

If not for the fact that Dustin was sitting there, I would have turned into that crazy hysterical woman screaming at hospital staff in the hallway. I simply shook my head, rolled my eyes and left. I had a sick kid that needed me and deserved my attention and energy more than this clown who clearly had no interest in helping me or addressing my concerns.

Prescription Mistakes are just another reason being a parent is hard…

This shit right here. This is why parenting is exhausting, draining, and often leaves us feeling hopeless, helpless and ignored. This is why we are fierce mama bears. This is why we take nothing at face value and fight tooth and nail for our precious littles. This is why we push back, ask questions and advocate for our kids the best way we know how.

The only reason I even caught the dosage error was because of an offhand comment about diarrhea. When I dared to question it, I was met with nothing but resistance and indifference to doing what was best for my kid. All it took was one phone call that no one wanted to be bothered to make.

To all my fellow mama bears out there, stand your ground. Don’t even think about apologizing for making sure your littles are healthy and safe. I’m not saying you should be a jerk, but I do think you have every right to push back and ask questions when something doesn’t seem right.

There really are some outstanding doctors, nurses, corpsmen and pharmacists at the base and everywhere else. I’m fortunate enough to be related to one of the best nurses out there. We did have an amazing corpsman, a doctor who was kind, attentive and willing to spend as much time as necessary to answer every question.

I’m not even convinced it was the doctor’s error. And even if it was, that’s somehow not even what I’m mad about. He’s the one that took the time to educate me enough that I was even able to catch the mistake. It’s the push back and lack of caring when I dared to question the pharmacist. And then the fact that the hospital staff was completely indifferent to how they handled the error.


Military spouse and mom of one with experience in marketing, volunteer management and, most recently, web design, project support and copy writing. Currently leveraging a BS in Marketing from a top University to negotiate with a pint-sized version of myself. Outside of work and managing the household, I am a serial dabbler and have rarely met a craft or hobby I didn't enjoy. Whether it's painting, volunteering, or running through the sprinklers, there's always some small way to make every day its own adventure.

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