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The Consequences of Not Following Your Gut

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“Marlton Pediatrics is still on hold.” 

“Can someone please ring register?”

It was a typical swamped day at the busy pharmacy — incessant refill requests from clinicians inundated our fax machine, irate customers demanded price matches, and customer service wanted to know if they could refund patients who purchased ranitidine.

Jan, our technician, was helping our stroke patient locate her swallowing aid, and Jim had just clocked out for his break. Mr. Benes, a loyal customer, presented a prescription for dexamethasone 20-milligram quater in die to me.

Eighty milligrams of dexamethasone a day?! I thought to myself. That is double the max dose! We wouldn’t even give this much to treat multiple myeloma!

I turned to the customer. “Mr. Benes, I’m just going to check with your doctor before I fill this.”

As I glanced down at the prescription to call the office, I realized it was written by none other than Dr. Pope. Dr. Pope was only the most old-school, elderly, Eisenhower-era physician who still believed that doctor’s orders were never to be questioned. Regardless, I had to phone him about this error.

“Dr. Pope, this is Elizabeth calling from the pharmacy. I noticed that you prescribed a very high dose of dexamethasone for Mr. Benes. Forty milligrams is used to treat cancer, and that is the highest recommended dosage for dexamethasone. Why is he taking this much? At 80 milligrams per day, I’m thinking that you meant to prescribe prednisone instead, right?”

“Not that it’s any of your business, but he has chronic tonsillitis, and it’s just for 21 days until he has his adenoids removed. Why are you bothering me about this? Last I checked, I’m the doctor, and you’re the pharmacist. It’s my job to write scripts, and it’s your job to fill them. So you do your job, and I’ll do mine.” He then hung up the phone.

This isn’t right. I know that this dose is going to cause harm. How can I fill this prescription fully aware that Mr. Benes may experience psychosis, seizures, worsening infections, or arrhythmias?

“Mr. Benes, I’m really sorry, but this dose is way too high —”

“CVS is on line two for a transfer!”

Mr. Benes smiled. “Elizabeth, I appreciate your concern, but if it were a problem, Dr. Pope wouldn’t have prescribed it. Please just fill it as is. My throat’s killing me, you have a call to attend to, and I just want to go home.”

“Marlton Pediatrics now wants to speak to the pharmacy manager!”

This is wrong. I could potentially hurt this man. But this is what the physician wants, and all I have to do is document his approval. I mean, I did call the doctor after all, right? Even if something happens, I can’t be held responsible. Besides, it’s not like it’s oxycodone, amiodarone, or warfarin. Dexamethasone is not known to kill people like those drugs. Mr. Benes is in a lot of discomfort, and I’m just holding him up, as well as myself and the pharmacy. I think I’m overreacting. I’ll just fill it and send him on his way.

“Have a seat, Mr. Benes. I’ll have it right out.”

I filled Mr. Benes’ prescription, and he went home to rest. Three days later, Mr. Benes’ wife stopped by the pharmacy to tell us that her husband was hospitalized after suffering a perforated colon from a dexamethasone overdose.

He died a week later.

After I heard this tragic news, I was inconsolable. Devastation consumed me, and I couldn’t go back to work for a week because I was so distraught over this death that I partially caused. The guilt that this was my fault is something that I will never get over. I knew that I should have reached out to Dr. Pope again, but I was too afraid to argue with him. Instead of placing the patient first, I was more concerned about singeing an old man’s ego.

As pharmacists, we have a responsibility to refuse to fill prescriptions that can place our patients in danger. When something doesn’t sit well with us, we need to follow our gut. Never again will I feel compelled or pressured to dispense anything, especially if it is blatantly wrong. The lesson I learned from this is that a patient’s safety must always be our No. 1 priority. Sometimes, we are their only advocates, and we have to do right by them, even if it’s the hard thing to do.

Have you been in a situation that put you between an order and your gut? How did you react? Share your experiences below.

LCDR Elizabeth Moham is a Senior Assistant Pharmacist for the United States Public Health Service and is currently stationed at the Federal Bureau of Prisons.  She also works part time at Walmart Pharmacy.

The author has no conflicts of interest to disclose.

All names and identifying information have been modified to protect privacy.

All opinions published on Op-Med are the author’s and do not reflect the official position of Doximity or its editors. Op-Med is a safe space for free expression and diverse perspectives. For more information, or to submit your own opinion, please see our submission guidelines or email

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