Imagine going to the pharmacy to fill your prescription only to learn later that the drug your doctor prescribed is not the one you received. The prescription was switched without your knowledge or permission.
Not just switched to a generic version of the prescribed drug, but to a different drug altogether.
That is exactly what happened to Amy Detrick, who said her pharmacist switched her epilepsy medication without her permission.
"When you get to that place where your seizures are under control with a dosage that's correct you don't want to mess with it," she said.
Detrick said the switch ended up sending her to the emergency room with a broken leg and fractured eye socket after she had a seizure while riding her bike.
She said the new medication prompted her seizure.
"Had I been behind the wheel of a car, I could've caused an accident. I could've put my car around a telephone pole," Detrick said.
Detrick's neurologist said the pharmacy didn't inform him of the change either.
"Changes in the blood level because they get a different kind of medication can be a big problem. If it gets too high, she feels badly, too low, she has seizures," said Detrick's neurologist, Dr. J. Layne Moore, associate professor of clinical nneurology at the Ohio State University College of Medicine and Public Health.
Yet the practice of swapping out medications is perfectly legal in most states. It's called "therapeutic substitution" and it happens when a patient is switched from to a cheaper medication in the same class of drugs.
The move may be from a name brand to a generic, but it also can be to a different medicine entirely.
Cholesterol-lowering drugs, antidepressants, epilepsy drugs and medicines that reduce stomach acid are switched the most, according to the National Consumers League.
"We believe that if a patient is switched from one drug to another," said Sally Greenberg, executive director of the league, "that it should not be legal unless the patient and the doctor have been informed and are on board with the switch."
The National Consumers League recently conducted a survey and found two out of three people who had their prescriptions switched never were told.
The organization believes pharmacies make the switch to save money.
"Insurance companies absolutely are putting pressure on doctors to switch people. They're putting pressure on pharmacies to switch people," Greenberg said.
America's Health Insurance Plans, an industry group, told "GMA" that patient safety is top priority and insurance companies push for a switch only so medications will be more affordable for patients.
The American Pharmacists Association said prescriptions only should be switched with the doctor's permission and when it's best for the patient.
"Pharmacists do a lot of different things to protect your safety and your health, but I think the patients, too, need to start realizing that, in some cases it's good to ask questions," said Kristen Binaso,senior director of corporate alliances for the American Pharmacists Association.
Detrick agreed and hopes her story will help prevent other dangerous switches.
"I think the first thing they need to do is to be aware," Detrick said. "Do not be afraid to ask questions and seek information."