Check Your Medications Before You Leave The Pharmacy!

I recently made a trip to a local pharmacy to pick up an oral liquid antibiotic for my son who had a sinus infection. After waiting in line for a few moments it was my turn to speak with the young lady who asked for the name on the prescription. While in line I had watched the young lady answer the phone, work on the computer and run from one side of the pharmacy to the other. Once I gave her the name on the prescription she disappeared for a brief moment and came back verifying the birth date for my son. I declined counseling, paid for the prescription and out the door I went. It was around 8:25 p.m. when I returned home. I grabbed an oral dispenser from the cabinet and removed the prescription from the bag believing I was going to administer my son his first dose. When I picked up the prescription bottle I noticed it was unusually light and then I noticed it had not been reconstituted with water. Oops!
 
I picked up the phone and called the pharmacy to see how late they were open and explained that I was in to pick up my son's prescription and when I arrived home I found out it was not reconstituted. She stated they were open until 9:00 and would take care of me right away. Back in the car and to the pharmacy I went. When I went up to the counter I spoke with the pharmacist this time and she apologized and shared with me that someone did not place the "Add Water" label on the prescription bag so the technician didn't reconstitute.
 
What was wrong here? The technician should have read the medication when retrieving it and known by the medication type that it needed reconstituted.  The pharmacist or whomever was placing the bottle in the bag should have added the sticker reading "Add Water." I should have opened the bag and verified the prescription was correct. I also should have quickly realized the bag was not heavy enough and that the young lady was not gone long enough to have reconstituted the antibiotic. Knowing about pharmacy practice and having direct sight to the Graduated Flow Thru Cylinder they use for reconstitution, I should have asked why she didn't add water.
 
How many patients and parents picking up prescriptions don't know anything about pharmacy practice? How many patients automatically assume that they always will have the correct medication? How many people check their prescriptions before leaving?
 
We know pharmacies are very busy places and warning labels as well as some really nice technology advances such as barcode checks have helped ensure patients get the correct medication. We also know that humans are involved and nobody is perfect. I believe that patients/consumers need to become better educated and should habitually double check their medications before leaving the pharmacy. If I had done so I would have saved myself a trip back and the hassle. What if I didn't know it needed water and tried to give my son powder?
 
This pharmacy may consider some procedural changes to make sure this type of thing does not happen. The technicians may need refresher training. As pharmacists and technicians continue to multi-task with other responsibilities the likelihood of errors will increase. This is one reason I believe that consumers/patients need to actively take a role to ensure their own safety as well.