A woman was written a prescription for sleeping pills, but she went home with an anti-psychotic drug and said she almost lost her mind.
Now Donna Duncan, a Mid-State woman, has sued in federal court, accusing the pharmacist of making a big mistake.
Her case might make people think twice before assuming they're always getting the right medication.
Consider this: nearly five billion prescriptions have been filled every year in the U.S., and two percent have been mistakes.
It may not sound like much, but that means millions of patients get the wrong pills. For Duncan, that was a big problem.
"I was praying to God let it pass, and the other prayer was take me home. I just wanted it to end," Duncan said.
She has suffered from restless leg syndrome and went for her usual prescription -- Ropinirole -- at a CVS pharmacy in Gallatin.
Duncan said she took it home, swallowed three pills, and her nightmare began.
"I didn't know what was going on," she said. "I was hallucinating. My body felt like the limbs were detached from me. I had terrible nightmares."
Then Duncan woke up talking crazy to her husband and daughter, Molly.
"I started telling the story of being two years old out to sea, and I witnessed a murder," said Duncan.
"I was like, okay, something is not right," Molly observed.
Duncan's daughter immediately noticed her rational, sensible mother was talking out of her head, so she checked her pill bottle for the Ropinirole.
"It says this is a pink round tablet with the 'HH' on the back," said Molly.
But the pills she found inside were not pink, and they were marked with the letter "M."
"Wrong pills in the right bottle with the right name with the right dosage with the right patient," said Clint Kelly, Duncan's attorney.
Kelly has sued Tennessee CVS Pharmacy in federal court alleging his client was given the wrong pills.
"Clearly some safety protocols were bypassed," Kelly said.
He said Duncan was mistakenly given Risperdone, an anti-psychotic drug meant for schizophrenics.
"Serious mental patients in hospitals... everybody but Donna Duncan," Kelly said.
"I didn't know what was going on," Duncan said.
She had to be hospitalized for taking the dose of Risperdone, which she did not need.
"They started pushing IV fluid to push it through me," said Duncan.
She said the traumatic experience where she seemingly lost her mind has continued to haunt her.
Duncan added something like this could happen to anyone, so what does she do now if she needs a prescription?
"Every single time I fill a prescription, I see the pharmacist, we open the bag, and see the medication, and he must reassure me that it's the medication it's supposed to be," said Duncan.
Attorneys for CVS have filed a response denying the allegations of negligence and recklessness.
They have been asking to have the lawsuit dismissed.