Pharmacy Error Could've Killed My Babies!

[petergabrielfan]

So, I'm not one to rant and rave like this, but I feel the need to right about now. Last week the pediatrician put my 6 week old twins on a liquid medicine for reflux. Two bottles were supposed to last us almost 90 days per baby. After a few days I began to notice that we were going through the medicine very quickly. I called the pharmacy (not sure if I should mention the name) and asked the pharmacist, who was not the one who filled the prescription. When I initially got the medicine, the pharmacist marked the dropper with a permanent marker to show how much to dose the babies. Yesterday after the pharmacist compared the dosage we were told to give at the pharmacy with the dosage that the doctor actually prescribed my heart sank. I had been told to give my babies 50x more than the doctor prescribed. So, my 8 lb. babies were being given WAY more meds than they should've been.

I made a frantic call to the pediatrician. Luckily they told me that this was a very safe medication (Zantac) and there was really no long-term concern. They did tell me to report the error to the pharmacy's corporate headquarters in case something does arise in the future.

The district pharmacy manager called me back and was very kind and concerned about the entire situation. I also spoke to the managing pharmacist at the pharmacy where the error occurred and he asked me to bring the droppers in so he could show the pharmacist her error. I refused to turn both droppers over so that I would still have some proof that the error was made. I did take one over to them so they could show the pharmacist her error. She marked the 4 ml line when she should've marked a point less than .8 ml.

In hindsight, I feel so lucky that my babies are ok and I just wonder how this ever happened. I know mistakes happen, but this is inexcusable, in my opinion. My doctor had already done the math for them so there was no conversion necessary. It makes me think about people whose children aren't so lucky when these mistakes happen. Had this been a painkiller or an anti-convulsive or some other drug, she could've killed someone. :sad:

[Dengineer]

So, I'm not one to rant and rave like this, but I feel the need to right about now. Last week the pediatrician put my 6 week old twins on a liquid medicine for reflux. Two bottles were supposed to last us almost 90 days per baby. After a few days I began to notice that we were going through the medicine very quickly. I called the pharmacy (not sure if I should mention the name) and asked the pharmacist, who was not the one who filled the prescription. When I initially got the medicine, the pharmacist marked the dropper with a permanent marker to show how much to dose the babies. Yesterday after the pharmacist compared the dosage we were told to give at the pharmacy with the dosage that the doctor actually prescribed my heart sank. I had been told to give my babies 50x more than the doctor prescribed. So, my 8 lb. babies were being given WAY more meds than they should've been.

I made a frantic call to the pediatrician. Luckily they told me that this was a very safe medication (Zantac) and there was really no long-term concern. They did tell me to report the error to the pharmacy's corporate headquarters in case something does arise in the future.

The district pharmacy manager called me back and was very kind and concerned about the entire situation. I also spoke to the managing pharmacist at the pharmacy where the error occurred and he asked me to bring the droppers in so he could show the pharmacist her error. I refused to turn both droppers over so that I would still have some proof that the error was made. I did take one over to them so they could show the pharmacist her error. She marked the 4 ml line when she should've marked a point less than .8 ml.

In hindsight, I feel so lucky that my babies are ok and I just wonder how this ever happened. I know mistakes happen, but this is inexcusable, in my opinion. My doctor had already done the math for them so there was no conversion necessary. It makes me think about people whose children aren't so lucky when these mistakes happen. Had this been a painkiller or an anti-convulsive or some other drug, she could've killed someone. :sad:

Two of my kids were on Zantac and I've heard it is very safe too and nearly impossible to overdose on. It was good that you were paying attention and took action. I still live in terror of accidentally overdosing one of my kids--I always read the directions two or three times and usually have DH double check it. Some medications can be very dangerous to babies. I am VERY glad your babies are ok now!!

[auntsashie]

Glad they are okay! I can't imagine how horrible this was for you!

[wvmommy]

Thank God your babies seem to be ok!! I can't imagine how scary this must have been for you...

[FunnyFace]

Oh Sarah! I'm so glad your babies are okay! That pharmacist would never fill another prescription for me again, ever! If she was a pharmacist, maybe she was a tech and if that is the case a pharmacist should be required to confirm all information is correct. Honestly, I'd probably would have gone ballistic.

[CW&M Mom]

So you know....liquid zantac has alcohol in it. Zantac may be considered a very very safe drug....but the alcohol in it....when you get too much, or with a few other drugs, can cause issues.

All 3 of my kids have been on liquid zantac...and all 3 put onto other stronger meds...because liquid zantac just tastes nasty...and they wouldn't willingly take it.

[VANILLAGRRL]

I am so sorry that this happened to you! I am ultra paranoid about giving any medicine to my kids or DH and I. If it is a pill, I usually check the pills against a few pictures and descriptions online to make absolutely sure that I have the right pills. I saw an episode of Dr. G on Discovery Health where a teenage boy was given methadone instead of the generic ritalin he was supposed to get. Sadly, the mistake was only caught after he had died. Kudos to you for being so aware and catching this mistake. I am so glad that your precious babies are ok.

[moxi]

Terrifying!! So glad they are OK. Pharmacy's make mistakes often(in my opinion). I was once given medication for an infection, turns out I was taking some sort of heart medicine (I can not remember the name, years ago)due to pharmacy error.

[aurorahorse]

VERY scary! This may make you feel a little better...4 is five times larger than .8, so it was "only" five times larger than it should have been. Better than 50 times, but still way too much!

[CW&M Mom]

I am so sorry that this happened to you! I am ultra paranoid about giving any medicine to my kids or DH and I. If it is a pill, I usually check the pills against a few pictures and descriptions online to make absolutely sure that I have the right pills. I saw an episode of Dr. G on Discovery Health where a teenage boy was given methadone instead of the generic ritalin he was supposed to get. Sadly, the mistake was only caught after he had died. Kudos to you for being so aware and catching this mistake. I am so glad that your precious babies are ok.

I saw one...where the boy went to the ER for a soar throat...and the ER doc gave him a script for morphine...totally not kidding. The pharmacy filled it wrong...and they overdosed him the first time:sad:...so sad.