Pharmacist FINED $300 after pt dies from mis-filled prescription

The pills look similar but the Lamotrigine, the seizure medication, is slightly larger than Labetalol, the high blood pressure medication. (FOX19 NOW)Man claims wrong medication from Kroger accelerated kidney failure

http://www.fox19.com/story/32756952/man-claims-wrong-medication-from-kroger-accelerated-kidney-failure

A few years ago the OH BOP revoked a Pharmacist license when a tech mis-filled a IV for a 3 y/o and the Pharmacist was charged/convicted of manslaughter and spent 6 months in prison.

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CINCINNATI, OH (FOX19) –

A Cincinnati man is fighting two battles right now. One for his life and the other against grocery store giant Kroger.

Without a kidney transplant Randy Crews will die. The other battle awaits in a court room currently scheduled for Sept. 6 in Hamilton County.

Crews is being represented by Chris Macke, who is the husband of FOX19 NOW Anchor Tricia Macke. 

This battle stems from receiving the wrong medication from a Kroger pharmacy located on Kenard Avenue.

FOX19 NOW contacted Kroger and their lawyer for an official statement and interview, but did not receive a response from either party.

In court documents filed with the Hamilton County Court of Common Pleas by their lawyer, it reads, “[Kroger] has admitted to mis-filling [Mr. Crews] prescription.”

The online records go on to read, “The only relevant issues to this case are what damages, if any, were directly caused by ingesting of the mis-filled prescriptions three months after it was filled.”

The grocery store giant contends that Crews was already sick before there error ever came into the picture.

Crews and his attorneys don’t see it that way.

For five days Crews thought he was taking his prescription called Labetalol for his high blood pressure. Instead, he was taking Lamotrigine which is for seizures.

He picked up the medication in December of 2013, but didn’t take start using it until April of 2014. In the short time he took it, Crews said his blood pressure became elevated. “He was severely disoriented, dizzy and vomiting, to the point of dehydration, and feeling as if he was dying,” the lawsuit reads.

His wife felt something was wrong and felt his symptoms were brought on after he started using what he thought was high blood pressure medication.

The suit reads Crews’ wife brought the medicine to a competing pharmacy where she was informed by them that her husband was taking seizure medication and not high blood pressure pills.

FOX19 NOW obtained a picture of both medications. The pills look similar but the Lamotrigine, the seizure medication, is slightly larger than Labetalol, the high blood pressure medication. The other difference between the pills are the labels. Lamotrigine is labeled, “ZC 82” while Labetalol is stamped with “NT & 042.”

According to the lawsuit, the pharmacy tech was placing the pills in a vile when he was alerted by a computer system that there was an error, and the tech overrode the computer system. It further said that another tech simply looked at the pills, which looked similar, but never properly inspected them making sure they were the right pills put in the bottle. None of the documents give clear indication as to why the pharmacist overrode the system causing the wrong medication to be given out.

Crews went to the hospital for five days and was diagnosed with Acute Renal Failure, resulting from dehydration and elevated blood pressure, according to the lawsuit. After being released, Crews said he was diagnosed with stage 5 kidney disease and chronic renal failure.

Before he started taking the mis-labeled medication, he contends he was at a stage 3 level, and after his prognosis became downgraded.

According to the lawsuit, Crews now has two options; A kidney transplant or daily dialysis, which he contends prior to taking the medication that neither option was needed.

Online records show the manager of the pharmacy said she has never reported errors made to any governmental agency or pharmaceutical board. She explained she does not know what Kroger does with the information.

Kroger lawyer, Christopher L. Moore argued that, “they have no obligation” and they don’t have too.

FOX19 NOW obtained documents from the Ohio State Board of Pharmacy in 2012 showing the dangers of wrong prescriptions. Although the board could not say how many times patients in Ohio have been given the wrong prescriptions, we did obtain documents showing some of the cases in years past in which it’s happened.

Among the most startling cases:

A West Chester pharmacist received a prescription in June 2010 for the sleep aid Ambien, but gave the patient Glimepiride instead, according to a settlement agreement FOX19 NOW obtained. Glimepiride is a diabetes drug. Three months after getting the wrong prescription, the patient died.

Another West Chester pharmacist, Ohio State Board of Pharmacy Records show, received a prescription for 120 tablets of morphine sulfate in April 2010, but gave the patient 360 tablets of methadone, the drug used to wean people off of heroin. The settlement agreement with the pharmacist shows the “patient was subsequently harmed,” but it doesn’t say how badly the person was injured.

These settlement agreements with the Ohio State Board of Pharmacy also revealed the punishments the pharmacists received.

The pharmacist in the case of the patient who died was fined $300 and ordered to complete ten hours of continuing pharmacy education.

In the other West Chester case where the patient was injured, the pharmacist was fined $250 and ordered to complete five hours of continuing education.

2 Responses

  1. The blame lies with Kroger for paying more attention to metrics and profits rather than patient safety.

  2. The entire staff responsible should be suspended, and have to take a class on basic pharmacy safety.

    There should be mandatory reporting for pharmacy errors.

    That being said, people do need to be responsible for knowing what their medication looks like, if visually impaired, have another person verify the medication.

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