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You are the pharmacist-in-charge at a community pharmacy. While working your shift on a particularly busy day, you receive a call from a patient stating that their medication looks different from the usual tablets they receive. You ask the patient to read the imprint code on the tablets, and you realize that they were dispensed metolazone instead of metoprolol. You believe that a technician manually bypassed the barcode scan, and you missed this error during the verification step.

You ask the patient if they can immediately bring the medication vial back to the pharmacy. The patient agrees and states that they have not yet taken any of the medication.

About 20 minutes later, the patient arrives at your pharmacy. Please counsel the patient on the medication dispensing error that occurred.

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