Mom sounds alarm about drug errors

March 3, 2008 4:40:33 PM PST
Drug giant Rite Aid responds after child's medicine was mislabeled

A Northeast Philadelphia mom is sounding the alarm about prescription errors, after her young daughter got a dangerous overdose.

15-month-old Shayne Coleman, who has an immune deficiency, was given a prescription for antibiotic liquid to treat a sinus infection.

Samantha Coleman had the prescription filled at the Rite-Aid in the Morrell Plaza, near her home.

Although Shayne got sick after the first dose, neither Samantha nor her doctor initially realized what was wrong. "It says on the bottle it could upset your stomach a little bit," Samantha remembers.

After 3 days of vomiting and diarrhea, and when Samantha realized the bottle wouldn't last for the 60 doses it was supposed to, she called doctors again.

That's when she was told Shayne should be getting 3 milliliters of the drug, not what she says on the label - 3 Tablespoons. After calling the doctor, who contacted a poison control expert, Samantha says she was told, "It was a dose high enough to shut her kidneys down."

Samantha says she didn't get any satisfaction from the local pharmacist, who she says was rude on the phone. Samantha then took her complaint to Rite Aid's headquarters in Harrisburg, Pa., "I had to call the corporate office, and they apologized to me. One guy called me back every day, asking if she was OK. It took a few days for the medicine to get out of her system."

Rite Aid tells Action News there was a mistake, but differs with Samantha Coleman on the magnitude. The company says the label on the bottle called for a 3 teaspoon dose, not 3 tablespoons, as Samantha Coleman contends.

After the mistake came to light, Rite Aid says workers at the Morrell Plaza store were re-trained on safety procedures.

Cheryl Slavinsky, the company's director of communications, says it has also re-enforced the company's 7-point check system, which throughout its stores. That system calls for: checking the name, address, date-of-birth for prescriptions; checking the medicine name and strength; scanning an image of the prescription, the stock bottle, to put into Rite Aid's own computer system; scanning the stock bottle to verify the label; and checking the medicine name and strength against a hard copy of the script.

Samantha says parents, doctors, and pharmacists everywhere have to be more vigilant, because mix-ups could happen at any pharmacy.

She worries, "I don't want somebody to make the same mistake with another child who has an immune deficiency or that has a sickness, and can't defend themselves."

Samantha Coleman says she was fortunate, that Rite Aid responded to her complaint. She contacted several attorneys about her case, but found they weren't interested, because, as a letter from one firm notes, "it wasn't a lethal dose."

Prescriptions errors are one of the most common medical mistakes. The National Institute of Medicine has made it a top priority, in and out of the hospital, as it works to reduce errors. A national pharmacists group estimates that just this year, there could be 150 million prescription errors.


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