You don't have any questions for the pharmacist, do you?: A fatal methadone overdose

Terry Paul Smith, a 46-year-old roofer, suffered from a disorder of the peripheral nerves (neuropathy) in his back and legs, which kept him in chronic pain. He took Oxycontin and Neurontin, but he disliked the way it made him feel, e.g., making him sometimes "drop out" in the middle of a conversation. After he mentioned the pain meds' side effects, his doctor changed the prescription to methadone, a narcotic pain reliever. The doctor wrote a prescription for Terry to take four 10-milligram pills, twice a day.

Terry filled the prescription at a local Walgreen's pharmacy in Jacksonville, Florida. In handing over the pills, the pharmacy employee asked, "You don’t have any questions for the pharmacist, do you?" They didn’t.

Though Terry didn’t know it, the label on the medication vial was incorrect; it directed him to take four tablets "as needed for chronic pain," and did not mention any limits on the frequency. Terry took the pills for the first time on July 23-24, 2001.

Within 36 hours, he was dead. An autopsy that his widow insisted found toxic levels of methadone in his blood.

The pharmacist had mislabeled the pills as "take as needed" rather than take "twice a day."

Now Terry's widow, Pearl Smith, is pursuing a lawsuit against Walgreen's. Next week, the jury will begin considering the case.

A company spokesman says Walgreen's has spent $1 billion over the last decade on pharmacy safety systems, safety training and technology. Walgreen's filled more than half a billion prescriptions in the last fiscal year.

Advice: Read the doctor's prescription and check it carefully against the label, especially for a new medicine.

Read an informed consent story, or read more from the source article by Kevin McCoy in the USA Today of Nov. 2.

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.

I couldn’t make it without my friends: A wrong drug error

Sharon’s story (last name withheld by request):

I had been on Effexor for a good five years at different levels; I had been decreasing it for a long period of time, but had also been using free samples the doctor had given me, for years. They come in those packs that you push through, and I collected them from other people, so I was happy to have them for free.

When I ran out and the drug company stopped sending them, I had to get a prescription and go to the drug store for the first time in a lot of years. I took the script to Sam’s; they were great; they handled it. I had it filled and started taking them.

I started not feeling well pretty immediately, but I didn’t realize that. The next two days, I started not feeling well. My symptoms were nausea and dizziness; I was light headed, and extremely tired. I had to come home from work about 3:00 to lie down. A couple of days later, I called my doctor (not the one who’d prescribed the Effexor) and they fit me in and I went in that day, because I’m not usually sick. My friend Joan says I’m always zooming around, but saw that I wasn’t at all. I started having heart palpitations--that scared me.

I went to the doctor’s and first he was convinced I was pregnant! He wanted to do a pregnancy test! But I knew I wasn’t. I had an EKG, and they did a lung X-ray--all these tests! Everything checked out OK, and he basically told me to give it a few more days. It probably was Day 8 now, and I was laying on the couch feeling crappy and Joan came over, and we were talking about all my symptoms, and she asked me all these questions: Have you been eating anything different? Are you taking a new kind of vitamin? Have you changed pharmacies? She said she read an article in Newsweek that the pharmacies made mistakes all the time—she had just read it, and that’s how it started. I told her I didn’t change pharmacies, and she asked if any of my pills looked different, and I realized they did. But because I’d been getting free samples, I didn’t put it together –I was like an idiot--because a lot of times they do.

So the next day, I still took the pill, like an idiot, and I went to the doctor, and I asked him for a copy of the prescription, and I told him what I thought might’ve happened. The doctor pretty much knew when I told him. So I took the scrip and the 9 pills that I’d taken out of the 30-day prescription, and I took it to the pharmacy, and said, Is this what I am supposed to have here? They said they have a hard copy on their computer files—I didn’t know they could do that. And they looked at the script and the bottle, and went, “Woops! This is not what we filled”!

They immediately gave me another bottle of 30 of the right timed release ones. They told me that they were sorry, and they didn’t charge me for the new bottle.

The next day I got a phone call from the pharmacist that prescribed it, apologizing, and wanted to know how I was feeling. The same day, I got a call from an independent insurance agent of some kind, who said that by law they had to report on the error, and she asked me to tell the story of what happened as well.

Three days later, I got a call from the same woman, who said that she was able to make me a one-time settlement if I was prepared to accept it today. I said, “What settlement?!” And all this information came out of the blue for me. I told her I was NOT willing to make any kind of settlement, that I needed a couple of days to think.

She had made me an offer of $1,200.

I called my friend who is an attorney, and we talked strictly as friends—I wasn’t paying him anything. And he explained to me that this could be a huge lawsuit and the company was trying to avoid it, and that I needed to think about how I felt about all of this. I explained to him that I was never thinking about suing, and that I was not comfortable with the idea of getting a lot of money from them. My friend explained to me that I had a legitimate complaint and deserved to be compensated. So we talked about different options as far as my pain and suffering, how much time I missed from work, and all my doctors’ bills—I was concerned about that because I work for a nonprofit, for nothing, practically, and I was concerned about all the medical bills I had just created.

So we came up with a number that covered all my medical expenses and covered me missing a week of work--$2,200.

Now, I still feel that Sam’s has been the best pharmacy for me over the years. They’ve been great, before, and since. Now I always open the bottle of pills when I get there. Mistakes can happen anywhere. It’s a business, but it’s human beings filling the scripts. It’s scary, I tell everybody: Check your meds!

I had two advocate friends. My life is run by my friends. I couldn’t make it without my friends.

Advice: Get a friend like Joan and Sharon’s lawyer friend to advocate with you.

Read a story about another victim who chose not to sue .

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.

The Machine Was the Perp: Wrong drug errors

Most American hospitals place automated drug dispensing cabinets on the patient floors, to enable nurses to give drugs to patients more promptly. Usually this is a good thing, but the convenience comes with an awful high hidden price.

The families of six premature babies, and hospital staff, have learned that grim lesson. The babies were being cared for in the neonatal intensive care unit of an Indiana hospital. The NICU was equipped with an automated drug dispensing machine--imagine a candy machine that requires a nurse's password instead of money to activate. A pharmacy technician had stocked it with the ADULT doses of heparin, a powerful blood-thinner meant to prevent blood clots that could clog intravenous tubes. Then, over time, as nurses opened the cabinet's drawer to get heparin for their preemie patients, they took the adult heparin, and gave it to six different preemies. Three of the babies died and three remain in critical condition.

Advice to hospital pharmacy directors: Store hazardous medications in the pharmacy, not in the automated dispensing machines, to prevent multiple errors.

Advice to parents: Check the label of each dose of medication your family member receives. In choosing a hospital, ascertain whether hazardous medications are stored in automated dispensing machines. A patient advocate may be useful for this purpose.

Read another of our stories about a drug error lawsuit, or read more about this one in "Family of 3rd preemie to die of overdose speaks" and "Drug Error Triple Tragedy in Indiana."

The 10-Week Medication Error, continued: A look-alike drug error

To prevent look-alike drug errors like the one that afflicted Donna Ulliman, pharmacies should make similar drug names look different. For example: meTHIMazole and meTOLAzone look very different. Compare that to the CVS computer screen, where METHIMAZOLE and METOLAZONE look somewhat similar. Pharmacies could also use different typefaces for different syllables of the drug name, e.g., by using the Tallman font.

Read our earlier posting on this.