YOUR NOT ALONE AND NEITHER AM I !!!!!!!!
I really thought how could this be happening and the only thing I can figure out is it can happen with a miss matched refill. You describe the change exactly. I didn't think anyone else was seeing this an I was crazy. I called a staff member in and showed her what it was doing just because I couldn't believe my eyes.
Did you report it? When I reported it the tech told me he had never see this bug before. Are you on version 12.4?
I have just inactivate the changing medication and start over.