Dan Morehead caught his pharmacy's error before he took something he should have. He first noticed holding a new bottle of the pills, and an old one that something was off with his chronic pain medication.
"I noticed that the bottle that they put the pills in was a slightly different size was like that seems like a little odd," he said.
Morehead counted the pills to make sure he had 90. The number was correct, but something still wasn't right.
"As I was putting them away, like I noticed on the back of one of them that it said 800," Morehead said.
His usual dose is 600 milligrams. He had his medical-student girlfriend look up the pill. Morehead found out he was given too high a dose.
"Somebody's grandmother is like not going to pick up on that difference," he told the I-Team.
Morehead believes he wouldn't have been severely hurt by the higher dosage, but he took to Twitter to share his concerns with Walgreens, where the prescription was filled.
The I-Team contacted the company. A spokesperson responded via e-mail.
"We have a multi-step prescription filling process with numerous safety checks in each step to reduce the chance of human error and have reviewed the process with our pharmacy staff. "
"There's some professions that we put systems in place and we sort of don't allow mistakes," Morehead said.
Walgreens tells the I-Team mistakes are rare. We went to the state agency that monitors pharmacies to find out if that's true.
In 2017 the Kaiser Family Foundation reports Wisconsin pharmacies filled more than 65 million prescriptions.
In 2015, 2016 and 2017 combined, the state got 450 complaints about dispensing errors.
Not all of those were substantiated. But, pharmacies have to file state and federal reports for all controlled substances they can't account for.
The I-Team discovered 108 of those reports from the last three years.
These are the top three reasons drugs went unaccounted for:
Drugs lost in transit
There were a total of 35 instances in which pharmacists wrongly filled, miscounted or simply didn't know what happened to controlled substances.
"Our systems are fallible," said Tracy Kosinski, a professor at the Concordia University of Wisconsin School of Pharmacy.
Kosinski teaches an entire class on improving patient safety.
"We are trying to reduce the human interaction within the system and within the process," she said.
Kosinski said "to err is human," and that all human error can't be taken out of a system. But, her job is to help students analyze where errors might happen, then use technology and create systems to prevent those errors. She also teaches a team-based approach, encouraging students to help patients understand every part of their care.
"Then when they're looking at their medications and they're sitting at home they can compare that to their previous discussion and hopefully serve as the last line of defense," she said.
That's exactly what Morehead plans to do from now on.
"Should I have to do that? No," he said. "But, it's probably one of those things that I'll start to."
Kosinski said if people can't check their own medication or fully understand what they're supposed to have, she recommends finding a family member or caregiver who can become a part of your medical care.