37 Tablets Missing

I fill an Rx for generic Xanax for a seriously whacked-out dude. It is for quantity 60. Because it is a controlled substance, we count them multiple times. I remembered counting these tablets because the generic has an odd shape and it is hard to count. I document on the label that I counted the prescription twice. The guy gets his medication and leaves.

Four hours later he calls me to tell me there is only 23 tablets in the bottle. I put him on hold and go to the bottle on the shelf and do a back count. The back count is spot on for what the computer says we have. I tell the guy on the phone. He says someone else must have his medication because he definitely has only 23 tablets in his bottle. He says he went straight to work, put the bottle in his desk, then when he went to get a tablet later he thought the pile of tablets looked small so he counted them and that there were only 23.

Now you know, I'll be the first to admit that pharmacists make mistakes. In most cases Pharmacists count by fives, and 99.9% of the time if there is a miscount it is either off by one tablet or five tablets. But this guy is saying I shorted him 37 tablets. So I think back to how this could possibly have happened. Just to make sure, I check ten prescriptions that were processed on the computer before he came in and ten prescriptions after. I pull every bottle on the will-call shelf and make sure all the correct medication is in the bottles that we still have on the shelf. I call the people that picked up their medication during this 20 prescription window.  Everything checks out. And like I said, I distinctly remember counting out 60 of the rectangular-shaped tablets. I counted them twice and placed a check mark on the label each time I counted them, just like I do with all controlled substances.

I explain all this to the patient. He still insists that I made an error. When I suggested that maybe someone took medication out of his desk, he says that's not possible. I asked him if he was at his desk for the past four hours. He says no, not all the time, but that he's sure no one was in his desk. Of course I have no idea how he knows this, but we're a "give the benefit of the doubt" kind of company, so I let it go.

I told him that he would have to talk to the manager. He did call the manager and a regional manager. They backed me up on what I was saying (miracles do happen). I was hoping he would transfer out the medication to another pharmacy, but instead when he ran out of the 23 tablets he insisted on a refill. I called the doc for an early refill request and explained what happened. It was approved. This time I filled the medication again, but counted to 60 three times, and documented it on the label. Then I did a back count of what we had on hand.  It checked out too.

The whacked-out guy who NEEDS to be on Xanax comes in. Would you believe he stood there at the counter and counted the tablets in front of me, and when he was done he says, "There's only 58 here!" All I could do was sigh. That's all I could muster out. Really? Seriously, dude? Do you think if I actually stole your medication before that I'm actually going to try and do it again? Is this paranoia part of the reason you're on the medication? I grabbed a counting tray and in front of the patient counted out the 60 tablets. Three times. He stood there, silent.

I still don't know exactly what happened to the 37 tablets, but I'm thinking miscounting had something to do with it, but not from me...