Her Only Kidney: A drug error lawsuit

Tiffany Phillips had been born with only one kidney. She had a kidney transplant, and was discharged from the hospital to her home in South Carolina. The hospital’s doctors hoped the prescription they wrote for prednisone would keep her body from rejecting her new kidney. The medicine was not in stock at the Eckerd pharmacy, so the pharmacist there called a pharmacist at CVS. The pharmacist saw an alert on the CVS computer, but overrode the alert, and filled the prescription. Unfortunately, the pharmacist had dispensed the prednisone in 1,250 milligram doses rather than 250 mg doses, and the young woman took a five-fold overdose.

She was soon hospitalized and again is needing a new kidney, her lawyer said. Unfortunately, the mistake has left her with few alternatives. After taking too much of the steroid, she is unable to use dialysis. And she cannot have another kidney transplant. The error has reduced her life expectancy. The judge and jury considered that in awarding her an $8 million judgement against the pharmacy. The jury found the pharmacies 90% responsible. They found Tiffany 10% responsible because she had not noticed the correct dosage on her hospital discharge papers.

Advice to pharmacies: Require pharmacists to document their reason for an override of a computer alert, to discourage overrides. Require the approval of a second pharmacist to override computer alerts for medications for fragile patients, e.g., those who have just received organ transplants.

Advice to patients and advocates: Carefully verify the medicine label against the hospital discharge prescription.

Read another story of a drug error lawsuit, or read more about this one in Taylor Bright's newspaper story.