Pharmacy Errors and Children

Pharmacy Error Nearly Causes the Death of Another Young Boy

May 21, 2014 | Lebowitz & Mzhen

Earlier this year in Crystal Lake, Illinois, a five-year-old boy ended up taking a dangerous dose of an anti-psychotic drug when the pharmacy gave the drug to his mother under the auspice of a treatment for his allergies. According to a report by the local NBC affiliate, the young boy, Ali Ahmed, was in need of medication for his allergies, and a prescription was called in for him at the local Walgreen’s pharmacy.

When his mother went to pick up the prescription, she picked up what she thought to be the allergy medication that her son’s doctor had called in. However, the pharmacist gave her Halperidol instead, a dangerous anti-psychotic drug used primarily to treat adults with serious mental health issues.

Luckily, the boy’s parents only gave him a small dose of the wrong medication. After young Ali took the medication, he slept for two days straight. After waking, he had a small snack, and his neck began to flare. Emergency personnel were called, and eventually the flare went away. However, as soon as the neck flare went away, he began to act strangely and then fainted. His parents called the boy’s doctor, who told them to take him to the hospital immediately.

Pharmacy Allegedly Dispenses Adult’s Prescription to Child with the Same Name, Resulting in Near-Fatal Drug Reaction

February 20, 2014 | Lebowitz & Mzhen

The family of a five-year old boy in the Chicago area is claiming that a case of mistaken identity resulted in the boy receiving the wrong medication and suffering a near-fatal reaction with possible long-term health effects. They have filed a negligence lawsuit in Cook County Circuit Court seeking $50,000 in damages. Pharmacies and the medical professionals they employ owe a duty of care to consumers to verify not only the type and dosage of medication dispensed, but also that the correct patient receives the correct medication.

The child reportedly had a routine checkup with a physician in January 2012. The doctor discussed allergy medication with the boy’s parents, but did not write a prescription at that time. A Walgreens pharmacy allegedly called the family two days later to tell them that their prescription was ready. Believing it to be the allergy medication they had discussed with the doctor, the boy’s mother picked the prescription up and began giving it to him according to the instructions on the bottle.

The lawsuit, filed in January 2014, states that the boy slept for almost two full days after taking the medication. When the child woke up, he exhibited unusual symptoms. His neck flared, leading his parents to call 9-1-1, but it soon subsided. The boy later fainted, so his parents took him to the doctor, who told them to go immediately to the hospital. The prescription that they thought was for allergies, they learned, was actually haloperidol, an antipsychotic medication intended for an adult with the same name as the child.

Hospital Allegedly Gives Infant Incorrect Dosage of Medication for Meningitis Treatment

February 6, 2014 | Lebowitz & Mzhen

The parents of an infant allege that a California hospital is responsible for injuries that required their child to go on life support. Hospital staff reportedly administered far more than the prescribed dosage of medication while treating the child for meningitis. Doctors, nurses, pharmacists, and other medical professionals have a very high degree of responsibility to their patients and the public. A catastrophic injury can result from a seemingly simple pharmacy error, such as a misspelled word or a transposed digit that causes a patient to receive far too much, or not nearly enough, of a drug.

According to news sources, the child was born several weeks premature. He was calm and quiet at first, but began to get “fussy” when he reached one month old. A doctor diagnosed him with viral meningitis, an infection of the membranes around the brain and spinal cord that can be debilitating or fatal if not treated promptly. The child’s parents took him to a hospital for treatment.

A physician at the hospital prescribed an antiviral medication called Acyclovir. After the drug was administered, the hospital pharmacist reportedly told the family that the child had accidentally received about ten times the prescribed amount. The child’s heart stopped several hours later, and his brain started swelling. According to the most recent reporting, he had some brain activity but required the use of a ventilator. The child’s father said that hospital staff told him there was not much more they could do for the child, who was by then six weeks old. One possible option, as described by the press, was for the hospital to provide a ventilator the child could use at home.

Lawsuit Over 4 Year Old Girl Given Five Times Correct Dose of Medication

October 21, 2013 | Lebowitz & Mzhen

The family of a young girl recently filed a $750,000 federal lawsuit against her local pharmacy, alleging that the business wrote the incorrect directions on her prescription for a seizure medication, causing the girl to take five times the proper dosage of the drug.

According to the lawsuit, the little girl was given a prescription when she was four years old for two milliliters of an anti-seizure medication, to be taken twice a day. However, when the prescription was filled, the instructions stated that the girl should be given two teaspoonfuls twice a day. One teaspoon is the equivalent of almost five milliliters. The pharmacist in the case stated that she repeated the dosage back to the doctor at the time it was filled, and it was confirmed as written.

The young girl’s mother stated that immediately after giving her daughter the incorrect dosage, the girl suffered a serious seizure requiring immediate hospitalization and treatment at a local hospital. According to the lawsuit, the girl became catatonic, and the girl was later transferred to a Children’s Hospital where she remained unconscious for some time. Once she regained consciousness, the girl was unable to walk, and had to be fed baby food, resulting in a 17-18 pound weight loss. She reportedly still suffers side effects from the incorrect drug dosage, and is afraid of taking medicine.

Mother Sues Pharmacy over 6 Year Old Daughter’s Death in 10x Correct Dosage Case

August 22, 2013 | Lebowitz & Mzhen

A mother is reportedly suing her longtime pharmacy, claiming that a dosage error led to her daughter’s death.

The woman claims that her 6 year old daughter died after taking a dose of morphine 10 times higher than what she was prescribed. The little girl had been taking the liquid painkiller during the course of treatment for sickle cell anemia. Sadly, this tragedy comes on the heels of a report regarding similar errors in the administration of pain medications in young children.

The lawsuit alleges that the young girl died in April 2012, just one day after taking the hyper concentrated dosage. It further claims that the girl’s cause of death was officially ruled “morphine toxicity.”

Study Examines Cause of Errors in Opioid Infusion Errors in Children

August 8, 2013 | Lebowitz & Mzhen

Of all of the types of pharmacy and medication errors that are made, some of the most frightening to think about are those that occur with children.

One recent study (registration required) focused on errors made with pain medicine, specifically opioid infusions in children.

The researchers in the study analyzed patient safety and pharmacy data in search of potential critical incidents in patients receiving opioid transfusions over a five year period, from December 2004 to December 2009. Those incidents that scored at least an 8 out of 10 for seriousness were then further investigated in order to conduct an analysis regarding the cause of the error.

The researchers initially identified 166 potential incidents. Out of those, 58 incidents included one (45) or more than one (13) relevant critical incidents. According to the researchers, the most common incident was opioid administration error, which had occurred in 39 of the cases cases (67%).

Fourteen of the incidents were isolated for root cause analysis, which identified 31 root causes. The most frequent and significant ones involved defective preprinted order sheets for the opioid infusions; lack of nursing guidelines for the infusion adjustment rate and weaning off the medication; and inadequate policies and guidelines for monitoring and recording pain, vital signs and arousal. Most significantly, the errors were attributable to an issue with policies/procedures, communication errors, environmental/equipment issues, and inadequate training.

While researchers were not able to study the potential impact of fatigue because the study was retrospective, they did identify one major problem, which involved the transferring of patients between units. The errors were more likely to occur at that point in time because there was no standard set of policies and procedures, increasing the potential likelihood for error.

Pharmacist’s License Revoked Following Dangerous Drug Mistakes

June 24, 2013 | Lebowitz & Mzhen

A Rhode Island pharmacist, and former state senator, has had his license revoked from the state earlier this month (registration required), following the accidental administration of morphine to two children who received medicine from the pharmacy where he worked.

The Health Director, Michael Fine, ordered the pharmacist’s license to practice revoked, stating the seriousness of the errors, and that a third serious dispensing error of this nature could lead to the potential death of a patient. This was reportedly the second time since 1999 that a pharmacy under the man’s control had made a major labeling error.

According to the order, the man’s license was initially suspended in March 2012, when he acknowledged being the pharmacist in charge of a location where the two mistakes were made. According to the report, two children, aged 11 months and 2 years, were mistakenly dispensed a medicine containing morphine and other serious pain reliever medications, instead of the drug they were supposed to receive in order to treat acid reflux and related conditions. The Health Director stated that this pharmacist has now had three disciplinary proceedings since 1999, and that the similarity and severity of the two incidents “demonstrate an indifference to proper pharmaceutical practice.”

Young Girl Narrowly Survives Morphine Overmedication in Hospital

May 6, 2013 | Lebowitz & Mzhen

The U.S. Food and Drug Administration recently updated one of its website pages regarding medication error and consumer awareness. One of the stories included is a cautionary tale for all hospitalized individuals receiving medication intravenously.

When a 9 year old girl shattered her elbow on the soccer field, her M.D. parents took great care in selecting a hospital for her treatment. Following a successful three hour surgery to repair her injury, the girl was prescribed morphine through a pump, and was also hooked up to a heart rate monitor, breathing monitor, and blood oxygen monitor. She responded so well, that doctors decided to turn the morphine pump off, and discontinue regular vital sign checks.

The girl’s mother slept in her daughter’s hospital room that night. When she woke up in the midde of the night to check on her, the girl was barely breathing, and was verbally non-responsive. Apparently, the morphine pump was not only still turned on, but in fact had been turned up to high. The narcotic flooded the girl’s body, but thankfully she survived the ordeal. It is disturbing to consider what may have happened if the mother hadn’t woken up when she did.

The parents in this case were satisfied with the manner in which the hospital handled the error, which included acknowledging the error, addressing future treatment for their daughter, and a plan for how to avoid such errors in the future. The mother believes that short staffing and a holiday weekend may have been contributing factors.

Study Examines the Use of Antipsychotic Medications to Treat Children with ADHD

January 30, 2013 | Lebowitz & Mzhen

A study published last year examined the rate at which doctors prescribe antipsychotic medications for children diagnosed with attention deficit hyperactivity disorder, commonly known as ADHD or ADD. The researchers found a significant increase in the rate of prescriptions in recent years, and psychiatrists may now prescribe antipsychotics for children or adolescents with ADHD in one-third of all visits. The U.S. Food and Drug Administration (FDA) has not approved antipsychotic medications for ADHD in children, making it an “off-label” use. While this is not illegal per se, it raises concerns about known and unknown side effects and the risks of dangerous medication errors.

ADHD is a mental health condition that affects both children and adults, and can severely impact a child’s functioning in school and other activities. Symptoms include easy distraction, difficulty focusing, irritability, and difficulty remaining still. The most common pharmaceutical treatment for ADHD consists of stimulant drugs like Adderall and Ritalin. According to the Centers for Disease Control and Prevention (CDC), ADHD affects about 5.2 million children between the ages of three and seventeen, just over eight percent of all children in the U.S. in that age range. About twelve percent of boys and nearly five percent of girls in that age range have been diagnosed with ADHD.

National Patient Safety Board Would Reduce Medication Errors, Say Celebrity Supporters

June 7, 2012 | Lebowitz & Mzhen

The National Transportation Safety Board (NTSB), the federal agency that reviews highway and aviation accidents and makes recommendations for safety regulations, could serve as a model for an entity to monitor patient safety, according to a number of celebrities and other advocates. A medical journal article co-authored by actor Dennis Quaid and airline pilot Chesley B. “Sully” Sullenberg III argues for the creation of such an entity to apply lessons of previous medication errors and other mistakes towards the prevention of future problems. They cite the NTSB’s success at recommending effective revisions to airline safety regulations.

In an article published in the March 2012 issue of the Journal of Patient Safety, Quaid and Capt. Sullenberg join a medical doctor and an attorney in calling for creation of a safety board for patients. All four authors have experience as jet pilots, and all four have experience in aviation safety. Quaid additionally has endured a medical “near-death experience” with his twin children. They describe a “healthcare financing crisis” due in part to inefficient healthcare spending and waste, based on decisions made by corporate boards and administrators rather than doctors. They recommend adoption of “best practices” based on past experience, similar to the way the aviation industry has improved safety with the assistance of the NTSB.