First thing in the morning: A Hero Mom and a leukemia drug overdose

Her four year old son Michael had just been diagnosed with leukemia. After he spent five days in the hospital, his mother brought Michael Koster home and filled two prescriptions for him.

That night, as Pam prepared to give Michael his first doses of the medications, she read the directions from the bottles and thought something was odd, she told ABC News.

"I said, 'This doesn't seem right,'" Pam said she recalled. Checking with the local children's hospital, she says her fear was confirmed: the pharmacy had mixed up the instructions on Michael's medications, advising Pam to give her son a much larger dosage of a powerful drug, Dexamethasone, than the hospital had directed and to give him much less of a second drug, Methotrexate, which was key to curing his leukemia.

"I went to Walgreens the next day, first thing in the morning," Pam told ABC News. "The pharmacist who filled the prescription was there. I asked to talk to him specifically. I showed him the labels and said, 'This isn't right. I want you to pull what the hospital called in and show me what you did.'"

The pharmacist said he did not have the paperwork handy but would look into the matter. At first she resisted, Pam said, but eventually gave in after being promised the store would call her later that day with more information. The pharmacist's supervisor called her that afternoon, Pam told ABC News. Pam says she admitted the error and vowed to bring it up at the store's next staff meeting.


In fact, as Dr. Marlene Miller at Johns Hopkins Children Center in Baltimore reported today, children with cancer often get the wrong dose of chemotherapy or are given the drug at the wrong time, and many require treatment because of the errors. She and her colleagues studied 800,000 errors, of which 310 involved kids on chemotherapy. Of those mistakes, 85% reached the patient, and one sixth of those were serious enough to require additional care.

Advice to parents of children getting prescriptions: Check the label carefully, and if you find an error, show up and tell them so.

Read another of our children’s overdose stories, or read the source story by ABC’s Brian Ross and Justin Rood.

Thanks, Kim Slack and Joe Brownstein.