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| Bradshaw & Bryant PLLC

The Medesto Bee had a scary, but informative example of the problems with mistakes at pharmacies. A five year old girl was suffering from symptoms of H1N1. Her pediatrician prescribed a antiviral drug. The directions were to take two doses over the next 24 hours. Her mother then received a call from the drugstore with the disclosure that "someone got the wrong medication."

The mother was then told that she had been giving her daughter a heart medication. Amiodarone, a drug used to treat irregular rapid heartbeat when other drugs fail. In following the dosing instructions for the flu medication, the young girl received two times the normal dose for the heart drug. The mom explained:

"They told me to take her to the emergency room right away," O’Neill said. "I raced home and called 911, and the paramedics came and put her in the ambulance."

The girl seemed OK when given an electrocardiogram at Memorial Medical Center in Modesto. But a follow-up EKG was irregular on Friday. O’Neill won’t know for sure if Ellen was harmed until they see a pediatric cardiologist next week.

According to the National Patient Safety Foundation, 30 million dispensing errors occur every year in the United States. A 2003 Auburn University study on pharmacy errors estimated they will occur four times a day at pharmacies filling more than 250 prescriptions daily. One in 1,000 of the errors are a threat to patient’s health, the study said. This number is startling.

Ways to avoid having a problem:

  • Don’t get a prescription filled at the beginning of the month.

David Phillips, a sociology professor at the University of California-San Diego who has studied this issue has found that in the first few days of each month fatalities due to medication errors rise by as much as 25 percent above normal. The reason: Social Security checks come at the beginning of the month.

  • Open the bottle at the pharmacy.

Mitch Rothholz, a spokesman for the American Pharmacists Association, said opening the bottle right at the pharmacy and showing the pills to the pharmacist is one safeguard. Another: If it looks different than the medicine you’ve taken before, or you have any questions, don’t be afraid to ask the pharmacist.

  • Don’t be in a rush.

Hedy Cohen, a spokeswoman for the Institute for Safe Medication Practices. says "When picking up drugs, patients want to get in and out quickly. We care if our food has butter or margarine on it. We really should be much more careful about the medications we put in our mouths." Cohen said patients should take the time to get detailed instructions about how to take a drug. Errors happen not just when the wrong medicine is dispensed, but when the right medicine is taken at the wrong dosage.

Hopefully the upcoming medical visits find the little girl to be OK. But, no matter what happens this should be a reminder to all of us that the drug which is prescribed needs to be the one that we give us and our families.


  1. David Mittleman

    excellant post mike - the big box pharmacy folks keep the pharmacist way too busy - people need to slow them down an ask question

  2. Gravatar for Mike Bryant
    Mike Bryant

    Good point on the size and speed issue. We have such a change going on in our neighborhood. Way to many incentives that leave the customer behind. Thanks for the comment

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