Most pharmacies in our area provide an important patient safety tool right on their prescription labels: a description of the shape, color and imprint code of the medication that should be inside. Yet few patients may realize this and fewer still use it. Independent pharmacies, mail order pharmacies and major national chains like CVS, Walgreens, Rite Aid and Target all have added this safety feature. With so much information on prescription labels, however - including patient and doctor name, drug name, instructions and warnings - the added information can easily be missed. But it’s important, so look for it and put it to use.
Exactly why this tool is important was illustrated this past week, when we heard from a patient who used the description to find out that her pharmacist accidentally dispensed the wrong strength of medication. When she got home after picking up a prescription for her heart and blood pressure medication, she read the pill description on the label before taking any. Immediately, she saw that the description didn’t match the appearance of the pills in the bottle. She called the pharmacy to question why the mismatch occurred - and learned that instead of 25 mg tablets of atenolol as prescribed, the tablets were actually 50 mg. That strength had caused side effects in the past, so she returned it and got the correct strength.
At the Institute for Safe Medication Practices, my colleagues and I have always encouraged patients to avoid taking or administering medications that look different than expected without first verifying that the medication is correct. That’s easy to do if you are renewing a prescription for a brand name drug, which is almost always available from a single manufacturer. Generic drugs, however, rarely if ever look like the brand name version, even though they are equivalent in safety and effectiveness. An example is the antidepressant Prozac (fluoxetine), which is widely used and available from 10 generic manufacturers; each is different in appearance.
In theory, patients can receive different looking tablets or capsules every time they refill their prescription when generics are dispensed. It mostly depends on where the pharmacy purchases the drugs, how rapidly their inventory turns over, and cost. Most pharmacies contract with manufacturers and try to stick with a single generic manufacturer for a certain drug over the long term, but that’s not always possible.
With such wide variation in a single medication’s appearance, and with constant interchanging of products due to drug shortages and generic equivalents, both patients and healthcare professionals have become somewhat complacent about doublechecking when the tablet, capsule or liquid looks different. Often they simply assume that the differences are the result of a different manufacturer's product being used. As a result, appearance no longer serves as an effective passive control feature.
The description that many pharmacies provide on the label can help assure accuracy since it’s based on the national drug code number (called an NDC number). These numbers are specific and tagged to the drug prescribed by your doctor and the product entered by the pharmacist into the pharmacy computer system. Even if the generic manufacturer is different each time the prescription is renewed, the description on the label will match the NDC number. So patients can quickly determine if the medication in the bottle matches the description on the label. If not, then something is wrong and needs to be questioned. Unfortunately, not all pharmacies provide tablet, capsule or liquid descriptions. So, to best assure safety, consider this a very important factor when choosing a pharmacy. In the future, technology will allow an actual picture of the pill on the label, but currently the printers used by most pharmacies cannot do that.
For safety reasons, I highly recommend that you do at least two things when you pick up your prescription:
- Seek out pharmacies that print descriptions - and make sure that the tablet/capsule/liquid in the bottle matches what is on the label.
- Always know what drugs you are supposed to be taking and check the exact name – many drugs have similar names, so knowing the exact name is critical - and strength of the medication on the label to ensure it’s what your doctor said you would be getting. This is important because the label descriptions that are the subject of this post cannot protect against the possibility that a doctor’s prescription, especially when handwritten, might have been misread or misinterpreted by the pharmacist, or that the wrong drug might have been selected on the pharmacy's computer screen. If that happens, the label description will match what is inside the bottle, even if it is the wrong drug.