Mother says 7-year-old son overdosed on prescription painkillers
http://www.wbrc.com/story/33132110/mother-says-7-year-old-son-overdosed-on-prescription-painkillers
Liquid Oxycodone comes into two strengths 1 mg/ml and 20mg/ml .. and the latter is normally reserved for end of life cancer/pain pts and it is administered under the tongue… which causes it to “kick-in” quicker. With the Pharmacist’s statement “Because typically it is a medication that was reserved for a hospice-type treatment.” Which would suggest that the prescriber wrote for the 20mg/ml strength which would probably be lethal for a opiate naive pediatric pt. It was also stated that the prescribed dose was 50mg – which would also suggest that the dose was 2.5 ml and using the appropriate strength of Oxycodone… would have given this kid a 2.5mg dose… which depending on the child’s weight… could be an appropriate dose. IMO… especially with the Pharmacist making that statement… SCREWED UP and didn’t do her job.
NASHVILLE, TN (WSMV) –
One mother said her son accidentally overdosed after he was over-prescribed an opioid pain medication.
Shelley Slater expected her son would be given medicine at the hospital. She never anticipated her then 7-year-old son would overdose.
“I was so scared I was numb,” Slater said, recalling the episode from 2012.
Slater’s son, Ethan, went to the Monroe Carell Jr. Children’s Hospital at Vanderbilt for a tonsillectomy. When he had an allergic reaction to hydrocodone, doctors wrote him another prescription.
Slater said she’ll never forget when she handed the script to a pharmacist at Walgreens.
“She told me that it was somewhat uncommon to have this even in stock,” Slater said. “Because typically it is a medication that was reserved for a hospice-type treatment.”
The prescription was for liquid oxycodone. The Channel 4 I-Team obtained a copy of the script, which displays a warning.
The message states the dose prescribed to Ethan—300 mg/day—exceeded the higher range of recommended dosage by nearly 3.5 times.
The recommended range on Ethan’s script fell between 2.655 mg/day and 84.96 mg/day.
Slater was instructed to administer 50mg to Ethan every four hours.
She said by the time Ethan took his second dose, something had gone terribly wrong.
Ethan was again rushed to Vanderbilt.
What happened next is detailed in her lawsuit against the hospital and Walgreens.
Documents state Ethan was suffering from respiratory depression and cardiac arrest.
Slater said her son had to be treated with Narcan, a drug that addicts are sometimes given, to reverse the overdose.
Ethan regained consciousness the next day.
“It is not a feeling I wish upon anyone,” Slater said. “It’s devastating, and I was fortunate I was able to have my child back.”
“Why in this world wasn’t this prescription checked?” asked Ed Gross, an attorney representing Slater. “Why wasn’t something done?”
For this specific drug, the manufacturer issued a warning stating errors in dosing could result in overdose or even death.
Sheila McMorrow is a doctor who specializes in pediatric emergency medicine at TriStar Centennial Medical Center in Nashville. She said warnings that monitor dosages are to be heeded.
“It’s very important,” McMorrow said. “I think anyone can make a quick mistake if they’re putting something in the computer and that’s what the safeguards are kind of built for.”
Slater said over time, she noticed changes in Ethan.
She claims Ethan now suffers from fatty liver disease, gastrointestinal problems and assorted behavioral issues.
In court filings, attorneys for Vanderbilt denied their acts caused Ethan’s problems, even though they acknowledge, “Ethan Slater apparently suffered some short-term consequences of having received too much oxycodone.”
Walgreens also rebuked the allegations, denying they filled a “prescription of a lethal dose,” and were negligent in providing reasonable medical care.
But Slater said she plans to continue fighting for her son.
“I just want him to be happy and healthy and we’re doing everything we can every day to do that,” she said.
Attorneys for Vanderbilt and Walgreens declined to comment on this story, citing ongoing legal matters.
Gross said he believes a mediation is scheduled for November.
They are asking for $750,000 from each defendant.
Filed under: General Problems
The prescriber holds some share of the culpability here too. I have to wonder why, if the child truly has a hypersensitivity (aka true allergy) to Hydrocodone, then why another Phenanthrene derivative would be prescribed. It is analogous to one being hypersensitive to Ampicillin and being prescribed Amoxicillin or Penicillin VK. There should also have been some attempt by the prescriber to note the Hydrocodone hypersensitivity on the oxycodone order. I realize that the mother should have also communicated the allergy, but the primary onus is on the prescriber.
Now to the pharmacy and the pharmacist. The knowledge of the allergy, if communicated, should have cause the bill ‘n’ fill wheels to grind to a screeching halt. Entered into the pharmacy prescription processing system (aka the pharmacy computer), the allergy would have tripped a soft edit that would have required the pharmacist to override in order for the claim to adjudicate. The fact that this medication is usually not utilized in the pediatric population should have been another red flag. On its face, the dose was wholly and completely inappropriate for a seven year old child. Another red flag. Again, the pharmacy computer would have triggered another soft edit known as a DUR warning that the pharmacist would have to override. Another red flag. Why did all of these red flags get bypassed? I cannot state with 100% factual authority, but knowing the chain operations in the way that I do (Steve, you know what I do for a living and I appreciate your discretion for not making that public), I can tell you that management is a slave driving whip cracker and production is king.
They drill the mentality into the pharmacy staff’s head that if the prescription is typed exactly as the prescriber renders it, then all is well. The pharmacist has a choice. He/She can subscribe to this philosophy and blindly crank out Big Macs,,,pardon, prescriptions as fast as is possible or they can. I know this on account of what I do for a living. It’s appalling the what comes out of a prescriber’s office that’s called an order and it’s even more appalling that the pharmacies are billing, filling and dispensing these orders without a second thought or even the minimum of a half-baked attempt to “clarify”, i.e., challenge the patently obvious clinical errors on the face of the order.
In the proper context (one out of dozens and dozens of reasonably possible contexts), the order may make sense. However, there is no way that the pharmacist is going to know this without having contacted the prescriber and clarified the order.
I’ve also found that the necessary contact does indeed take place, but it never gets documented. I can guarantee that if there is a bad outcome and the state’s Board of Pharmacy Inspector shows up and either takes the original order and all related records or makes copies thereof, that it’s not going to fly at the hearing when the pharmacist (whose license is about to be disciplined and will have to pay the heavy levy of fees and fines) states that all was good and fine because, “I talked to the prescriber and the scenario was .” When queried as to where is that documented and the pharmacist states, “Oh, I didn’t have time”, I can guarantee that the least punitive judgment against that pharmacist will be for failing to maintain a minimum practice standard of documentation and more than likely, the judgment will be more severe, including the fees and fines and revocation of said license.
Administrative law Proceedings are not like Civil or Criminal Proceedings. In these cases the Respondent, the Pharmacist, is guilty unless they can produce a preponderance of overwhelmingly exculpable evidence. Normally, the BOP, the Plaintiff as represented by the State AG’s Office, will not even get to this point unless they know that they can nail the license holder to wall. In most cases the State always prevails.
Ultimately, the pharmacist is ethically and legally bound to make contact and question orders, in a timely fashion (taken by the regulatory officials as before the medication is dispensed to the patient or the patient’s representative) that seem to contain errors on their face. This requires the pharmacist to contact the prescriber and get the order clarified, i.e., question what appear to be errors contained within the order. This could be the dose, the choice of medication for the particular, individual patient and any number of other things that we are trained in school to recognize and assess. See, at the end of the day, one either practices pharmacy for the benefit of the patient or for the benefit of the Mega Corporation. the Mega Corp is not your friend and will throw you under the bus to protect it’s interests. The pharmacist is just a 98 cent part in a huge machine, a part that can be easily replaced.
Unless the manifold BOP’s in this country do as the State of Oregon did and make provisions to hold the Pharmacy License holder equally culpable for for creating dangerous institutional policies like setting wholly unreasonable “Performance Metrics”, not minimizing distractions in the workplace and understaffing to save on labor dollars, then nothing will change. Patients will continue to be injured and/or die and the pharmacist, trapped between a rock and a hard place, will continue to have their many years of education and training nullified as their required “permission slip” to practice their profession, aka their pharmacist license, suffers legal disability or revocation (that is another issue for another time). I’m not holding my breath as most of the BOP’s across the US have one or more executives from one of the major chains or a member of one of the chain pharmacy trade groups as members. Talk about a conflict of interest.
In any case, as much as I abhor unions, as they become animals hungry for power in their own right, I don’t see any other way that the profession can organize and push back. More people will be injured and more people will die until there is a huge, media fueled public outcry. The result will be the State stepping in and dictating a solution to the issue, solutions that have the interests of the State and it’s patrons, i.e., the Mega Corps, as first consideration. The public and the profession will get screwed as usual. Either the profession takes control of the dialogue and then has a reasonable chance of having our informed solutions implemented or the profession will have to submit to another set of rules. BTW, did ya know that Pharmacy is the most regulated profession in the United States? Something to think about if that, as a status quo, is to change.
The very young and the very old are at great risk when prescribed liquids…this isn’t the first time that a chain overdosed a child and won’t be the last time. The chain stores have alerts built into their systems, however they can be easily bypassed, mostly due to distractions and time constraints because the Pharmacist fears failed metrics. Parents and caregivers need to be vigilant…ask questions and verify the dose.
Obviously the Walgreens company do not believe that pharmacists perform any legitimate functions whatsoever. If the pharmacist does not contact the doctor to ask why a tonsillectomy patient needs a med for an end of life cancer patient, then the pharmacist must not perform any function whatsoever, to safeguard the public. Under the construction proposed by Walgreens’ lawyer, the sole purpose for the laws governing pharmacy, is to protect Walgreens from free market competition. Pharmacist licensure must solely exist, to grant Walgreens the power to over-charge consumers for medicines and drugs, and is purely a sham that operates to provide Walgreens that overcharging privilege.
If the laws governing pharmacy serve any legitimate public purpose, in protecting the public from accidental harm caused by improper medication use, this is a case in which that protection should have operated, and did not.
I’m curious on the difference of respiratory distress and failure. The Doctor admitted on giving my mom too much pain medication and to let her die. Couldn’t they have given my mom narcan? Instead of killing her? Just seeing the difference of how they work on a child and let the elderly die or in my case, kill her. Glad the little boy made it, I hope Walgreens is found guilty.