You would think—and we often tell you—that your pharmacist is the primary gatekeeper when it comes to making sure the person you are caring for receives the right meds in the right dosages. So what happens when the pharmacist doesn't carefully watch the gate, so to speak, and you unwittingly receive the wrong drug or the wrong dosage of the right drug?

That's what happened this weekend when I picked up a refill of pravastatin, a cholesterol-controlling drug, for my mother. For two months I had been doling out the once-a-day oral medication that came in a vial indicating it was the 40-milligram dose, as instructed. The pills had a stamp on one side that indicated the manufacturer, and a number on the other side indicating the type and dosage of the pill. The problem came when I picked up a refill this weekend and discovered inside the new vial, which was identically marked regarding contents and instructions, a larger pill with the same manufacturer id but a product/dosage id number that was one higher than the pill I'd been giving my mother.

I immediately called the pharmacist, and maintained my calm while explaining the situation. After taking a moment to check on the id numbers, the pharmacist informed me that the drug was the same, and that the current pill was the correct 40mg dosage. However, he continued, the pill she had been taking, which had been dispensed by the same pharmacy, was only 20mg—half the dosage she was supposed to be taking!

I was upset. Fortunately, aside from not properly maintaining her cholesterol levels, the half-dose pravastatin wouldn't harm my mother much in the short term. But what if it had been a drug of greater consequence? Simply, it could have killed her.

The lesson learned? You can't depend on anyone. You have to double-check everything.

Don't be afraid, when picking up prescriptions, to open the vial and double-check with the pharmacist that the product you were prescribed is the product in the bottle. Take the extra few minutes required to be sure you received the correct meds at the correct dosage.

Simply checking in your copy of The PDR (Physician's Desk Reference) Pocket Guide to Prescription Drugs—a book every caregiver should have—will not do the trick, since many generic drugs, such as pravastatin, are not covered and certainly are not photographed as are many of the common brand-name drugs (in this case, Pravachol).

The minutes of care you take will save you from a lifetime of regret.