| Contents | Previous | Next |
An order was received in the pharmacy for birth control tablets to be given four times daily. The patient for whom the order was written had vaginal bleeding. Seven brown tablets remained out of a package originally containing 28 tablets. These were dispensed and administered for the first seven doses.
After two days, a fresh package of birth control pills was opened. The person administering medications was surprised to see a color difference in the tablets dispensed by the pharmacy the second time. The second tablets were pink; this was questioned. It was discovered that the original seven tablets dispensed that were brown in color were actually inert tablets. These remained in the package after the active pills (pink) had been punched out. Someone had returned the remaining inert tablet portion of the blister to stock. The patient was still bleeding after the seven inert doses.
The person using the active tablets should have made certain that the remaining tablets were discarded. Preferably, the iron tablets should have been punched out as soon as the package was opened for use other than as birth control pills.