Almost 6,000 people harmed by prescription erro... - Thyroid UK

Thyroid UK

128,538 members151,112 posts

Almost 6,000 people harmed by prescription errors in NHS last year

helvella profile image
48 Replies

We've seen a number of members describe issues with prescribing and dispensing issues.

With medicine issues - such as side effects and adverse reactions - we have the Yellow Card scheme. Although we might not always feel that these reports have the impact we'd like, at least there is a system in place. And we can lookup statistics.

Are any of you aware of a similar scheme for reporting prescribing/dispensing issues? Wherever they occur.

Of course, standard surgery, clinic, pharmacy or hospital (etc.) complaints can be raised. But one of the positive aspects of the Yellow Card system is that it is appropriate for reporting minor issues - as well as major. It also allows the reporter to be anonymous. Which might be highly desirable where a patient has no choice but to continue using the facility.

Trying to think of a suitable name! But nothing is coming to mind.

Almost 6,000 people harmed by prescription errors in NHS last year

Figures from NHS England also show 29 people were killed by prescription errors in 2021

A pregnant woman who died after being given the wrong dosage of drugs was one of almost 6,000 people harmed and 29 killed following prescription errors in the NHS in England last year.

Figures from NHS England show that 98 hospital trusts experienced an increase in the number of prescription errors reported in 2021, including cases where patients were given the wrong drug, wrong dosage or were not given medicine when needed. Meanwhile, the number of errors fell at 105 trusts.

Rest of Guardian article here:

48 Replies
Goldengirl01 profile image

this is not surprising, a lot of the time now I have to open the bag holding my prescription before I leave the pharmacy as they just don’t read what’s on the script. I can only take Mercury pharma t4 the brand is printed on the script but when Iv seen they have given me a different brand they say MP isn’t in stock at the moment and as we have read it could be very dangerous for people to have something different prescribed but they seem to think they are doing us a favour.

helvella profile image
helvellaAdministrator in reply to Goldengirl01

A situation that could possibly be reported anonymously and taken up with all pharmacies in an area - so that any possibility of the reporter being identified is minimised.

Goldengirl01 profile image
Goldengirl01 in reply to helvella

you have a very good point.

Charlie-Farley profile image
Charlie-Farley in reply to Goldengirl01

I do the open up at the counter - have given back meds at least 3 times in last year and a half. One had to be vigilant.

helvella profile image
helvellaAdministrator in reply to Charlie-Farley

Absolutely. Everyone should do this - if possible.

Suzanneharb profile image
Suzanneharb in reply to Goldengirl01

I 'shopped around' for a good pharmacist. The one I used to use became really arrogant ('you can take any levo, we know best' etc etc). The pharmacy I now use is wonderful! He goes the extra mile to get the right meds for me. I didn't have to explain myself - he had read the report that some people need to stick to one brand and totally agrees with it. In fact, I wish he was my Dr, lol!

Suzanneharb profile image
Suzanneharb in reply to Suzanneharb

(Although I still check my bag before I leave as I now have thyroid trust issues for life. Don't we all!)

helvella profile image
helvellaAdministrator in reply to Suzanneharb

While getting your business will probably be welcome, it is a shame that good service (from the patient point of view) doesn't get rewarded beyond a smile.

Suzanneharb profile image
Suzanneharb in reply to helvella

Totally agree!

Jaydee1507 profile image

Through an annual medication review with a pharmacist at my GP's surgery it turned out that my dose of Levo had been reduced without my knowledge and without a test. So one test later the dose got reinstated. No clue how that happened and it's worrying.

At the same review I discussed how a GP reduced my pain medication by text message with no discussion with myself. I could have complained and changed it but tbh I don't take it on a regular basis so what is written doesn't really matter. I would have been too angry to be constructive about it anyway.

These things happened last year during Covid. I feel terribly sorry for anyone who cannot keep an eye on whats happening with their prescriptions. The system is broken.

LindaC profile image

For some reason, this 'attitude' seems to be across the board - services - everywhere! What is going on!?

Valeriu profile image
Valeriu in reply to LindaC

maybe they want to privatise the NHS so don't care as much....Before readng this I was going to ask my Dr if he can prescribe Liothyronine 5mcg as the NDTs didn't work well for me Now am not sure ...:)

LindaC profile image
LindaC in reply to Valeriu

Some aspects have been hived off. I'd still try. xox

Charlie-Farley profile image

reporting prescription cock-ups 4U?

🤔 nope too long

Rep Pre Cock-Ups 4U

🤔 nope still too long and losing its meaning.

I’ll drink wine and get back to you (maybe). You know I’m not even surprised anymore. Horrified? Yes. Surprised? No……..

Charlie-Farley profile image
Charlie-Farley in reply to Charlie-Farley

Prescript-Wrong - a new dedicated system to gather all the cock-ups in one place. Hiring soon!

Hypopotamus profile image

I saw a pal at the weekend and asked him how he was. He was just out of hospital after kidney failure due to overdosing on Metformin. His dose was being increased each week based only on a telephone consultation, and no testing.

Litatamon profile image
Litatamon in reply to Hypopotamus

How awful. So sorry to hear.

helvella profile image
helvellaAdministrator in reply to Hypopotamus

This is in no way meant to blame your pal, but we can practice "self-defence" by thoroughly reading the Patient Information Leaflets for every medicine we take. Not just when we first get it, but repeatedly.

Hypopotamus profile image
Hypopotamus in reply to helvella

I have told him that, but I don't think that he will make the same mistake again.

waveylines profile image

Helvella this does not surprise me at all......Ive had serious mistakes made by GPs who dont know their pharmacology, pharmacists who miss items off (Pharmacies/GP blame each other). Watch channel 4 news last night (monday 26th sept) funding has changed for pharmacies so they cant make ends meet, despite all the extra duties they'v taken on in recent years to ease GP pressure so its anticipated closure of small pharmacies, already happening.

In hospital I dont allow the staff to manage my meds because it comes at the wrong times, and not given as instructed. Eg thyroid meds given with other meds after breakfast; incorrect dose given of heart regulating meds (really dangerous!) . I cant do anything when Im under an anaesthectic except pray they know what they are doing then....... 🙏🙏🙏

The government have been draining money out of the nhs, opposite of what they said they would do and now its broke. Now they've stopped the extra money that they were going to give to the nhs via raise in NIC but havent said how they will fund the nhs and social care this money. They just lie!! Am tired if it. Ive gone private because my referral was bounced to another department now bounced back to the very same deaprtment that GP referred me to last March 2022 . It will be March in 2023 before am seen for initial consult, never mind any treatment required......a whole year. Cant wait any more......

I genuinely fear for those people who are infirm or elderly or too sick to manage their meds/health and dont have family to follow things up for them.

All public services have been drained of funding for over 10years......and all are on their knees. Where has all the money gone? Well its disappeared into a small wealthy sector of the populations pockets....... The latest nonsense of cutting taxes makes me angry as you can expect services to collapse including education. Schools are switching lights off, keeping heating to an absolute minimum, no money for equipment and have already cut staff as much as they dare. Yet the gov recently talked of cut backs in public services!! Health, welfare and education will be domains for the rich only. Expect to have to pay out more and more as they will all become essentially private. Back to the victorian era. This has been their plan for years. Its working!!

Most of the errors we are seeing with meds are now down to poor training of staff, not enough staff, shortage of meds (pharmacists have recently been given powers to replace meds with simular when not available no matter whats written on a script) and inadequate funding to run a service effectively. All of these problems have been created by our government who are not inspected by any one except us the voters.

helvella profile image
helvellaAdministrator in reply to waveylines

Pointing everyone at pharmacists was a poor approach.

Most pharmacies I ever see are already too busy and don't have the time. Not unusual for them to be closed for periods from an hour to days due to inadequate staff.

Pharmacies as multi-functional professionals don't come free. But from how they have been promoted to us, patients, makes it look as is there is no cost. And no downside.

waveylines profile image
waveylines in reply to helvella

indeed Helvella....pharmacies are not free, they are funded or charge for their services eg delivery of meds to homes. As a nation we have allowed our government to squeeze our services dry of funds, by stealth. I work in a LA education statutory service providing for specialist needs, our budget fir equipment has remained the same for over 10years, demand for our service has increased higely, service staff level remsined the same......surprise surprise we can no longer provide the same level of equipment, basic equipment or the same level of service. A lot of it is done behind your backs so the public dont realise until the service is falling apart and the service gets the blame. Medicine errors are another symptom of this happening.

userotc profile image

As a family aware of these problems, we strive to be medication-free (even the dog!). Mum did have a bisoprolol for a while before we were able to wean her off it ~5y ago with bp controlled.

A big influence was my major side effects from prescription drug (continued after withdrawal) some which still exist. Yes Yellow card completed yrs ago, drug still on market....

Rhiansmama profile image

weve had two occasions where my daughters drus were doubled on her gliclozide (sp?) And blood pressure pills missing. Thankfully she knows her doses etc

helvella profile image
helvellaAdministrator in reply to Rhiansmama

Not everyone can be so aware. But the short time spent checking at every step, reading the prescription, Patient Information Leaflet, etc. and keeping aware are amply repaid by avoidance of issues.

2pence profile image

With the current pharmacy that my electronic prescription is sent to I don’t actually see the prescription they have. I can see that my prescription has been auctioned online using my login with the surgery but am not given a copy of it with my meds as have been before.

helvella profile image
helvellaAdministrator in reply to 2pence

That is a good point.

It would seem entirely reasonable to get an email with a clear statement of your prescription, or a link to it (for security that might be better).

We might need to campaign for that!

Otto11 profile image

An interesting read thanks for bringing awareness of it. I had no idea that it was so bad. Its scary.

Buzcat profile image

I have emailed our health minister to ask for another way to let people know about the yellow card scheme other than just in the inserts in a pack as most people have never heard of the yellow card scheme I also asked why pharmacists did not receive inf about keeping patients on a brand of Levothyroxine they do well on pharmacies are saying they can’t get Mercury Pharma yet there is no shortage it’s the suppliers that won’t supply it so I have asked him to look into this as it’s not cost effective to give a brand that make people ill I am awaiting his reply

helvella profile image
helvellaAdministrator in reply to Buzcat

I think pharmacists are expected (or required?) to display a Yellow Card notice. But there are so many notices, products, etc., all too easy to miss.

Buzcat profile image

no pharmacies in my area have it.

Mugs19 profile image

Strangely enough I have had 2 phone calls in the last few days which are to do with this very subject. Yesterday afternoon a pharmacist from my surgery rang me to do an annual prescription review. I have never had one before. He said it would take 15 to 20 mins. I had to end the conversation 50 mins later because I had to go out. I cannot get the whole conversation down on here which is a pity because bits of it resembled a Monty Python sketch. He wanted to know why I was on gaviscon. I told him because I have a hiatus hernia. He wanted to change this to PPIs. I told him I have tried them all years ago and have adverse reactions to them. He said that the Lodine I take will be upsetting my stomach and I| should try a different anti-inflammatory. I told him I have tried all the others but they either do not work or upset my stomach much more. In fact I take it because it doesn't upset my tummy any more and I have greatly reduced my usage of Gaviscon to a small dose at bedtime. He suggested I should take all my medications after food to reduce harmful absorption. I put him right on that one. Ended up explaining why my low T4 and TSH are low, it's because i don't need them as I get my T3 from the Pharmacy. Told him I may want to start some levothyroxine again and he warned me off. It is a high risk medication. At this point I asked him to explain why I was sold the RAI treatment because a hypo thyroid condition is easier to treat than a hyperactive one if the medication is high risk for the hypo one. He couldn't answer that one. I asked why when I had asked for a printout of my blood test results taken for my so- called diabetic review but I was given only T4 and TSH review. I had explained before hand that they need test only T3 for thyroid function but they hadn't tested it. Also there were no diabetes related results such as Hba1c. How was this a diabetic review? he found a result for that one . 35 so you are ok. No mention of FBCs etc. I told him that tick-box medicine was no use to me. He said he understood. then asked why I am on Sterimar. there are better alternatives. "like steroid sprays?" I asked . Have tried them all and am better off without them. I think he was relieved when I called a halt to it. the phone call I had last Friday is also relevant but I need to put up my own post for that as I could do with the benefit of the expertise (unparalleled) on here.

Jazzw profile image
Jazzw in reply to Mugs19

Well done.

But also…. Arrgghhhhh!

Buzcat profile image
Buzcat in reply to Mugs19

you are ñot the first one i have heard this from and i am not surprised with all the new brañds of medication thats being put out without trials you will get a different brand every two months.

Digger0 profile image

You could report it here

anjh-blue profile image

can you tell me how I can get access to a ‘Yellow Card’ or is that just an ‘alert’ option. Thank you

helvella profile image
helvellaAdministrator in reply to anjh-blue

This pinned post points you in the right direction. But they are not applicable to prescribing errors.

🟨 Making Yellow Card Reports 🟨

buddy99 profile image

First thing that came to mind: If the doctors don't get you the pharmacists will :D Not funny, of course in reality. Isn't it amazing that so many of us are still alive?

kiefer profile image
kiefer in reply to buddy99

I'm a pharmacist and I think it's sad that pharmacists know little to nothing about thyroid treatment, in particular, how different brands can have different effects or that some people need a little T3.

An RPh once refused to fill myT3 prescription, saying I hadn't given T4 a real good try. Even after the doctor called her, she still refused to fill it. Finally, she folded and told me that I should ask another RPh (in the same store) to fill it, but she wouldn't. Her safe space violated, she transferred to another store and that was the end of my troubles.

Pharmacists do make mistakes in filling but not for the reasons you might think. It has more to do with a failure to recognize a loss of focus. Much less to do with mis-interpreting a prescription due to sloppy handwriting. I can back this claim up to the fact that I worked in a mail-order pharmacy where we dispensed as many as 250,000 prescriptions per week. Some of the prescriptions that were filled wrong were type-written. When you lose focus, this happens.

buddy99 profile image
buddy99 in reply to kiefer

While it might be true that pharmacists know little about thyroid, doctors most likely don't know much more (if not less). My cousin is a pharmacist and I always, always ask him or my pharmacist here before I take a prescribed medication. Pharmacists can be a wellspring of info that doctors have absolutely no clue about. I would rather talk to a pharmacist than a doctor in many cases. Many very good experiences with them, not so many with physicians. I have even called a pharma company and talked to their medical advisor, who was a very good listener (and asker)and spent 20 minutes with me on the phone. Then he said that his company can not recommend the prescribed medication (not thyroid related) for me. Obviously I did not take it then.

helvella profile image
helvellaAdministrator in reply to kiefer


Isn't that sort of behaviour against some code of ethics? As well as the NHS contract?

It is a tragedy that we have such bizarre differences with some pharmacists seeming very aware and capable, while others "let the side down".

kiefer profile image
kiefer in reply to helvella

I'm in the US and pharmacists are allowed to refuse to fill certain kinds of prescriptions (most of the time it's for narcotics when someone comes in looking really dodgy). She apparently was a hard liner for T4-only treatment, no exceptions.

helvella profile image
helvellaAdministrator in reply to kiefer

Amazing! Thank you.

Wua13262348 profile image

I was left in the position of managing to get a prescription for liquid levo, plus a dose increase, but no liquid levo available (20/9/22) of any brand or dosage available for pharmacists to order in .

By a pure fluke, I got 1 bottle of Wockhardt liquid levo which will probably upset me. I know from the forum Teva liquid should be back in circulation at the end of September or beginning of October. Fingers and toes crossed on that one!

Boots ordered this in for me along with Teva liquid, a few months back, knowing Wockhardt didn't suit me, but Teva liquid did. They dispensed the Wockhardt to me, and when I said it was Teva liquid that was ordered in for me, produced a bottle of Teva. (Different staff member on duty dispensing in pharmacy from staff member who did the order.) Pharmacist must have ordered both brands to ensure Teva came and wasn't just sent Wockhardt, is the only reason I can think of that makes sense.

Turns out Boots still had the bottle of Wockhardt on the premises even though no one else ever wants liquid levo.

I gratefully took the Wockhardt from them, even though expecting it will upset me, and a slip owing me another bottle.

I know I need to stick to one brand. I started on 25mcg tablets 8/3/22. Since then, circumstances have forced me to be already on my 5th different brand!:

25 mcg Northstar levo with mannitol tablets, 25mcg Glenmark levo tablets, 50 mcg Teva liquid levo, 50mcg Brillpharma liquid levo, and now 75mcg Wockhardt liquid levo (from a 50mcg bottle as 75mcg is a special)!

I do not have the liquid levo on a repeat prescription, which is a pain, as it takes over a week for it to reach my pharmacy, and G.P. seems reluctant to make it a repeat. I am waiting for a first ever endo. appointment, which may be the reason? I assume the endo. would then be responsible for my prescription, and the cost of it?

I am in Scotland. A liquid levo prescription here seems to be a rarity!

I do not know how I can improve the situation I find myself in, and don't expect the situation will change or improve!

Any words of wisdom?

shaws profile image

"Almost 6,000 people harmed by prescription errors in NHS last year! "

No wonder so many people are afraid of taking medications that may harm them.

helvella profile image
helvellaAdministrator in reply to shaws

I suspect a tiny number set against those harmed when there was no prescription error.

birkie profile image

Hi helvella💖

Been trying to post this on my tablet but it keeps asking me to update my keyboard, I've no idea how to do that, my phone keys are to small to text but I'll try🤦‍♀️

Anyway I started on teva liquid levoroxine on Wed 28th Sept 50mg..before this I was on 50mg teva t4 tablets I have been having side effects of these T4 teva tablets for some time and my gp decrease me from 50mg to 25mg until I see the endo.. Saw endo 3rd Aug and she prescribed liquid levoroxine teva.. I started on the prescribed dose 50mg now 6 days in and I'm having all the same stomach /bowle problems again, it's hell bad cramping with mud like diarrhea, terrible bloating and awful grumbling in bowles the pain is so bad (like when I was on 50mg tablets) I can't do anything but crouch up until it eases, it seems worse when I eat to.. I'm now so sick of my surgery farting about with me.. Trying me on different thyroid meds chopping and changing my amount, I really can't decrease this liquid stuff, as I was hypo on 25mg t4 teva, so I'm sure 25mg of this stuff won't move my TSH down it was 7.4 in May this year so good knows what it is now on 25mg teva tablets since may🤦‍♀️really hoping this liquid stuff would work, I'm thinking it must be the brand teva.. (I'm lactose intolerant and have colitis)😭

helvella profile image
helvellaAdministrator in reply to birkie

Glad you could post.

The liquid and tablet products have entirely different ingredients. (Except the levothyroxine itself!)

Neither has lactose.

Some people do not tolerate mannitol (in Teva levothyroxine tablets), nor glycerol (in Teva levothyroxine oral solution).

I suggest you put in Yellow Card reports for every single product that causes you issues.

Have you ever tried Aristo levothyroxine? Only available currently in 100 microgram tablets. But it has neither lactose nor mannitol. (I would also suggest Glenmark but that seems to be unavailable at present.)

You may also like...