Big Prescription Error Shakes up Bountiful Mom
Tot gets 5 times too much of drug due to mistake
By Elaine Jarvik :: Photo by Tom Smart © Copyright 2006, Deseret Morning News
Deseret Morning News
Becky Vanderlinden was surprised last week when she looked at the dose instructions on the bottle of antibiotics for her toddler.
Becky Vanderlinden holds daughter Lily, who received five times the dose of antibiotics that her doctor ordered. Vanderlinden had called the pharmacy to check the dosage and was told it was correct. But the label was wrong. "I thought, 'This seems like a huge amount of medicine for a baby,"' says Vanderlinden, who immediately called the pharmacy to double-check. "The gentleman I spoke with said, 'This is the right dose."'
So, she gave 19-month-old Lily the 2 1/2 teaspoons of Omnicef and repeated the dose three more times. At that point the bottle was empty, so Vanderlinden called the pharmacy back. That's when she discovered that her original suspicions were right. It turned out the dose on the label was five times the amount the doctor had prescribed.
By then, Lily had severe diarrhea, and a couple of days later had developed a painful yeast infection. The whole episode has left the Bountiful mom a bit shaken — and with advice for other parents and patients: If something raises a red flag, trust your instincts. Don't be afraid to question.
According to a study conducted in 2002 by researchers at Auburn University, "errors associated with dispensing prescriptions are committed every day in pharmacies around the country." The study found that 1.6 percent of a sampling of prescriptions filled at community pharmacies in six randomly selected cities contained some type of error.
The errors included dispensing an incorrect drug, an incorrect form or incorrect amount, and labelling errors such as printing incorrect doses or instructions. The error rates were slightly higher for independent pharmacies than chain stores or health system pharmacies.
Occasionally the errors result in deaths or severe injury. In 2004, a Cook County jury awarded $21 million to an Illinois family whose daughter had permanent brain injuries the family alleged resulted when a pharmacy filled her prescription for anti-seizure medication with an adult diabetes drug.
Neither the Utah Department of Health nor The Utah Division of Occupational and Professional Licensing, which regulates pharmacists, keeps statistics on pharmacy errors. Like most states in the country, Utah does not require pharmacies to report those errors.
According to Utah Poison Control Center director Barbara Crouch, prescription errors that end up as calls to the center "happen very infrequently but do occur." The center has studied what it calls "10-fold errors" (doses that are 10 times more or less than the doctor ordered) in children younger than 6 years old and found that there were 29 calls (but these could have been either the fault of the pharmacy, the prescriber or the parent, Crouch pointed out).
Vanderlinden "did the right thing" by calling the pharmacy back to question the dosage, says Crouch. Those are the same words used by the manager of the Bountiful Walgreen's that filled Lily's prescription and by a spokeswoman for Walgreen's corporate office in Chicago.
"You should always question anything you're concerned about" when it comes to a prescription, says Lani Palauni, manager of the Bountiful Walgreen's pharmacy, who added that she can't comment on Vanderlinden's specific case because of patient privacy laws.
"We regret we didn't catch the error at the time," said Walgreen's corporate spokeswoman Carol Hively. "We have apologized, refunded her co-pay and provided additional treatment" (a cream for Lily's yeast infection). She said Walgreen's is investigating how the error happened.
The chain has a "multi-step filling and verification process the pharmacist should follow to ensure that the medicine is correct for the patient," she said. "We investigate every error to try to prevent it from happening again. We also have staff at our corporate office dedicated to preventing prescription errors."
As for Vanderlinden, she says the episode has made her nervous about future prescriptions. "I'm going to be a more informed consumer," she says. "In the past, when a doctor has handed me a prescription, I just put it in my purse and dropped it off at the pharmacy." From now on, she says, "I'm going to make sure it's legible and make sure when I pick up the prescription it's the same."
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Article posted by permission of the author 5/10/2007 © Copyright 2006, Deseret Morning News
E-mail: jarvik@desnews.com