Should you question the change in the appearance of your pills?

Dennis Miller, R.Ph. is a retired chain pharmacy. His book, The shocking truth about the pharmacy: The pharmacist reveals all the disturbing secretscan be downloaded in its entirety from Amazon for 99 cents.

Have you noticed a change in the appearance of your pills?

Do you have an obligation to question the change in the appearance of your pills when you fill your prescriptions? Are you guilty of contributory negligence if you have not done so, if an error has occurred at the pharmacy?

Do your pharmacists and technicians often seem stressed, and there are long lines of impatient customers at the pharmacy counter and at the window? Today’s reality is that pharmacies are very often very busy and dangerously understaffed. Is this a prescription for a pharmacy error that could harm you?

When you get your prescription refilled, have you ever encountered a situation where the pills you received look different than what you are used to? For example, the size, shape or color of the pills may differ from what you have received before.

Generic drugs can look completely different from their brand names and other generic versions

While generics must contain the same active ingredient as the brand-name version, the inactive ingredients (binders, excipients, etc.) may be different. In addition, the color, size, and shape of the generic product usually differ from the brand-name version.

This leads to a common scenario in the pharmacy where patients/customers receive pills when filling their prescriptions that look nothing like the pills they received before.

Should you ask the pharmacist?

Should I ask the pharmacy why the appearance has changed from previous refills? Or should we just assume that the pharmacy now uses a different manufacturer in the pills?

Are you reflexively told it’s a generic product from another company?

Have you ever asked about a change in appearance and been reflexively told it’s a generic made by another company? Does the pharmacist or technician reflexively give you this answer? Or does he take your questions seriously and take the time to research the pills?

If you’re calling from home, have you been reflexively told it’s the same thing from a different manufacturer without being told to bring the pills back to the pharmacy so they can visually inspect the pills?

Is that a mistake?

Is it reasonable to wonder if the pharmacy has really made a mistake? (They do.) Should you use an online pill identifier to resolve the uncertainty? Or should you google the numbers and letters on your pills to see if those pills are actually generic versions of what you should be getting?

Do you have the responsibility to question the change in appearance?

Do you have a responsibility to ask the pharmacy or the technician about the change in appearance? Or should you think that these are highly educated people who must surely know what they are doing?

Lawsuit in Alabama over changing the appearance of pills

If the pharmacist is sued, can he or his employer claim that you have a similar duty to question the change in the appearance of your pills?

In federal court in Alabama, the pharmacy argued that the patient/customer had a similar duty to question the change in appearance. However, the court refused to dismiss this case, where the pharmacy alleged the patients’ contributory negligence as a defense against malpractice.

It seems reasonable to conclude that most of the error lies with the pharmacy. It also seems reasonable to conclude that it is often inappropriate for the pharmacist to try to shift some of the blame to the patient/customer because they do not question the change in the appearance of the pills. But there may be exceptions.

Situations where the pharmacy can justifiably claim that the customer was involved in the error

It’s easy to imagine cases where pharmacists could more reasonably argue that customers were negligent by not questioning a very egregious pharmacy error.

For example, in a busy pharmacy with dozens of prescriptions being filled, it is not uncommon for one of John Smiths medications to accidentally end up in Bob Johnson’s bag. Is Bob Johnson contributing to pharmacists’ negligence by not reading the pharmacy label, taking the pills and not questioning the fact that John Smiths name is on one of the medicine bottles in Bob Johnsons bag?

Or Imagine a more extreme scenario. The patient/client fills in their own Prozac capsules. The pharmacy refill says Prozac, but the 6oz pharmacy bottle has some kind of syrup. Surely the customer would have a much greater responsibility to question an obvious pharmacy error, i.e. whether there is some unknown liquid medicine instead of the expected Prozac capsules.

Dispensing the wrong medicine is the most common pharmacy lawsuit

Pharmacy errors include dispensing the wrong medicine, the wrong dose, wrong instructions and ignoring significant drug interactions or contraindications (such as penicillin or sulfa allergy).

According to David Brushwood, pharmacist, attorney and pharmacy law expert

A medication error in the processing of orders is the most common pharmacy malpractice lawsuit.

Brushwood says,

In some circumstances, a patient’s failure to recognize an error involving the wrong medication can be a defense to a pharmacy malpractice case based on what is legally known as contributory negligence. (David Brushwood, Court Limits Patient’s Responsibility to Spot Pharmacy Inaccuracies, Pharmacy todayvolume 29, issue 12, December 2023).

Brushwood summarizes the facts of the case:

The patient had received both carvedilol and hydralazine from the defendant’s pharmacy for several years. Her lawsuit alleged that one time her carvedilol refill was improperly treated with hydralazine. He checked the label and found that the information on the label was correct. He didn’t contact the pharmacy because he trusted [the pharmacy] giving him the correct pills and he didn’t feel the need to check what he had been given.

He explained that when he saw the pill change shape and color, he thought it was another common pill because they change colors, shapes. He didn’t contact the pharmacy to make sure the contents of his medicine bottle were correct.

The patient claimed that he felt dizzy and lightheaded, his chest began to hurt, his heart was beating rapidly, and his blood pressure was over 200. He was transported to the hospital and treated for the effects of an overdose of hydralazine. His lawsuit alleged that the pharmacy had negligently placed 50 mg hydralazine tablets in a vial labeled 6.25 mg carvedilol.

The defendant pharmacy moved to dismiss the case arguing that since [the patient] knew that there were risks involved in abusing these drugs, he was complicit in negligence when he took the pills without trying to make sure the medication was correct.

Brushwood writes that the pharmacies’ motion to dismiss the case was denied. He recommends these takeaways:

  • Pharmacists cannot rely on patients to detect and correct dosing errors. The pharmacy is responsible for the accuracy of order processing.
  • Patients should be encouraged to ask the pharmacist if they have any questions about their medication, and all questions should be taken seriously.
  • If the appearance of the dosage form changes when the patient is offered a continuous supply, such as refilling with another generic product, the patient must be informed of the change.

Pharmacies should assume there is an error when they review prescriptions filled by technicians

I once worked with a very careful and conscientious pharmacist. He told me that when he checks the work the technicians are doing, he always assumes there is a mistake, and it’s his job to find that mistake before administering the medicine. This level of concern may sound paranoid, but I think it’s a good perspective for pharmacists to take. I think this is the kind of pharmacy you want to fill your prescription.

Seeing pharmacies and technicians up close can be a scary experience

You’ve heard the axiom that you don’t want to watch sausage being made. An analogous observation is that you might be scared if you watch pharmacists and technicians in close-ups as they fill prescriptions with astonishing speed. You may be eternally skeptical of pharmacy accuracy.

The pharmacy department is like a high-speed assembly line or a video game

When pharmacists or technicians lose their concentration for a fraction of a second, disaster can easily occur and the customer can end up with the wrong drug, the wrong strength, the wrong instructions, or serious drug interactions or contraindications (such as penicillin or sulfa allergy) can be overlooked.

When the pharmacist is the last person standing between the patient and the grave

I once read a comment from a pharmacy professor who told students to pay extra attention in class and study hard, not just to pass the next exam. He said students need to take their education seriously to become competent pharmacists when they are the last thing between the patient and the grave.

The business model of chain pharmacies is too little

The company management of the chain store sees the lack of personnel as a way to profit. In the opinion of many pharmacies, the company management of the chain store prefers to employ pharmacists as understaffed, because this forces all pharmacy employees to work overtime for the entire shift.

Don’t assume that chain pharmacies are adequately staffed for fear of pharmacy errors and resulting lawsuits. In the opinion of many pharmacies, the company management of the chain’s store thinks that it is more profitable to pay for the inevitable pharmacy errors than to staff the pharmacies sufficiently, so errors are rare rather than common.

Bottom line: Don’t assume your prescription is filled correctly

Don’t assume that today’s very busy pharmacies always fill prescriptions accurately. Study the pills and the directions on the label carefully, make sure your name is on the label, and question anything else that doesn’t look right. Pharmacy errors happen much more often than the public realizes.


This article is not intended to provide legal advice. In the case of a serious pharmacy error involving a change in pill appearance, your liability for failing to question this change in appearance may vary depending on the specific details and circumstances.

Dennis Miller, R.Ph. is a retired chain pharmacy. His book, The shocking truth about the pharmacy: The pharmacist reveals all the disturbing secretscan be downloaded in its entirety from Amazon for 99 cents.

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