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What would you do?

I picked up my prescription from my regular chemist which includes Plaquinil The box was white and labeled Plaquinal on opening it found that the tablets were different to normal ones, blister pack had Priadel written all over it, firstly thought that this was a cheaper version of Plaquinil Something didn't feel right so googled Priadel to my horror discovered its a drug used for the management of acute manic or hypomanic episodes.

My chemist was closed so contacted another one in the same group, The pharmacist was helpful and replaced the tablets with the right ones, offering his apologies on behalf of the other chemist. He has asked him to contact me on Monday morning, I'm concerned it could happen to someone else with serious results.

We take it for granted that the drugs are checked before being dispensed to stop any errors.

I feel I should do something about it but cannot find any information about where to make a complaint. Would appreciate suggestion.


14 Replies

Hi Anna, this is shocking. It was lucky you followed your gut instinct. I know one of the regular ladies on here would have details about complaints in pharmacy as she works in the pharmacy herself.

Good luck getting it sorted out.

Pet x


I always check each and every box and packet, pharmacists are only human, and as such prone to error, it's a good habit to check your meds carefully each month. I too have foundoccasional mistakes!

Scary, but not that uncommon..

Regards, Gina.


Sounds as if the chemist was part of a chain of chemists? Although it sounds mean, I'd probably write to management of the chain as they need to know that they could have been liable for nasty accident. Not precisely complaining, and not pointing finger at a specifci person, as accidents do happen, but asking them to check procedures.


Thank you for your responses, I'm not looking to blame individuals completely the opposite, I want to make sure it doesnt happen to someone who isnt as aware as many of us.. Gina you say its not uncommon for these mistakes to happen, then for that reason procedures should be improved to stop accidents happening.


Hi Anna, I'm afraid I disagree with some of the comments, yes the pharmacist is only human and we do make mistakes but this mistake could have cost someone their life. This error may not have been the chemists, the box could have came into their stock from elsewhere and they could have followed procedure and double checked the box and dosage.

This mistake could have happened anytime during the supply chain and could go back to the manufactures where there may have been problems in the making/boxing of the drug.

I think you should make a formal complaint, someone is guilty of negligence, potentially this could have had devastating effect on your health and you must consider if this has happened to you it could have happened to others more vulnerable than you.

Make a written complaint to the manager of the chemist and copy it to head office, let them investigate properly just in case this is a whole batch that have been wrongly boxed and not an isolated incident.

Beth xx


Hi bb, I totally agree with Beth.


I agree with Beth - this is worrying about a batch being wrongly packed. I will check my meds much more carefully in future. Thanks for this!



Of course it could have been a problem in the supply chain, I hadn't thought of that! My concern was about complaining just about a specific person in that it could be easier for the company just to discipline that person and not consider at all whether there are wider problems - for example people being over worked and not having time to check things, or no proper training and supervision. But I too will make sure I check my meds myself now!


HI It does need a formal complaint as it could be very serious & life threatening if someone is given the wrong medication.

Two people have to check all medication dispensed so it shouldn't occur.

This happened one to my husband when he was given the wrong insulin.

We made a formal complaint which has to be acted on.

Yes people can make mistakes but it could also cause someones death, especially an elderly patient who trusts everyone!


Thank you for all your comments will keep you updated with any outcomes.


hi all, this is terrible, that sort of mistake could kill heart patients, what if you was blind or trusting, The pharmacist has the responsibly to check all drugs leaving his chemist , My chemist has a assistant who counts the drugs and checks them and then the pharmacist rechecks, and I have seen them doing that as I wait . There is no excuse contact the manager of the group the pharmacist responsible for your drugs needs to pull his socks up and get more training . i would report to the link below.

have a look at this link



Both drugs are manufactured by the same company, so it could be a mix up at the factory.

However, either way, mistakes like this should not happen and if the fault lies with the manufacturer, they should be contacted to recall affected batches. The pharmacist should do this if that is the case.

I know this sounds trivial in comparison, but even high levels of vitamins can be harmful.

Every year, we have some of our lambs that need feeding artificial lamb milk (triplets, or lambs whose mothers havn't enough milk to raise them and yes, occasionally orphans). Last year, I noticed these lambs were not doing very well. It transpired that more vitamin A had been added to the milk formula than should have been (at post mortem they were looking for vitamin A in the liver of >10.4 - our lowest count was 4855.0 rising to 5396.0). What if this had been infant formula!!!

If the fault lies with your pharmacist, at the very least make a complaint to the head office, after all, who knows - this may not have been the first time a mistake has been made.


Hi I havent been on line.. had your pharmacy packed the tablets "down" into a plain white box?.. ie they werent in their original box?, if so this is a very serious error.. yes pharmacists are human but the contents of the box which may have been filled by an assistant should have been checked by a pharmacist.. on all medication dispensed their should be a white box for dispensed and a white box or similar for checked by.. there should be two sets of initials or signatures present.

Mistakes should always be reported. im glad you didnt take the priadel it is a lithium drug for manic depression/ pyschosis and it needs regular blood tests its quite toxic


Hi Summer, yes he had packed them into plain white box, I've spoken to pharmacist on the phone,in which he apologised saying he hadnt checked them.

I'm in process of going through the chemists complaints procedure.



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