When her daughter got the incorrect dose of a liquid drug meant to treat attention-deficit/hyperactivity disorder, or ADHD, a North Carolina mom claimed the pharmacy mistake made her unwell.
The mother said that when the 5-year-old child was given five milliliters of Quillivant XR per day rather than the one milliliter per day that was prescribed by a doctor, she filed a complaint with the North Carolina Board of Pharmacy.
Winston-Salem, North Carolina-based NBC station WXII broke the story first on Sunday.
The state organization attested to the existence of the complaint.
The mother said that due to the adverse consequences of the increased dose, her daughter was brought to the emergency department.
Since Quillivant XR is prescribed for patients 6 years of age and older, the prescription was most likely filled off-label. The kid is underweight for her age, according to the girl’s mother.
She said that after reporting the problem to Walgreens, a pharmacist informed her that she had misunderstood the order and was hurrying due to staffing shortages.
Citing patient confidentiality regulations, Walgreens informed NBC News that it was unable to comment on individual situations.
“The patient’s welfare is our first priority in the case of a prescription mistake. The firm released a statement saying, “We have reviewed this process with our pharmacy staff in order to prevent such occurrences. Our multi-step procedure includes several safety checks to minimize the chance of human error.”
Every year, the Food and Drug Administration receives more than 100,000 complaints of pharmaceutical errors—preventable incidents like giving the incorrect dose that might endanger patients or result in improper drug usage.
According to research conducted last year, between 7,000 and 9,000 Americans lose their lives to drug mistakes each year, while hundreds of thousands more have unreported side effects or consequences.
Adam Bursua, a clinical assistant professor at the University of Illinois Chicago College of Pharmacy, said that such dose mistakes are probably frequent.
According to Bursua, dosage mistakes are particularly common with liquid drugs since they are recommended in milligrams or milliliters, which are dependent on the weight of the patient in kilograms or pounds. According to him, it leaves space for simple math mistakes or transcription errors.Human error may inevitably creep in whenever people are required to type, compute, or transcribe anything by hand, according to Bursua.
Because many doctor’s offices and pharmacies don’t use the same electronic systems, Rita Jew, president of the Institute for Safe Medication Practices, a nonprofit organization that works to prevent medication errors, said that “sometimes the prescription will be dumped into miscellaneous fields” and the pharmacist will have to re-input it manually.
Confirmation bias is another problem. Pharmacists could search for dosages that make sense to them rather than ones that are customized for each patient. According to Jew, a lot of pharmacies are unaware of the weights and ages of their patients, which means that “sometimes you just don’t have the right information to even know that a dose is incorrect.”
Furthermore, she said that the workload is often excessive. According to a 2019 Department of Health and Human Services poll, employees in pharmacies often feel pressured to finish prescriptions quickly, and they find it challenging to work effectively in pharmacies due to interruptions and diversions.
According to Bursua, pharmacists are having more and more difficulty getting insurers to pay for their prescription drugs. Jew added that the COVID epidemic increased the frequency of vaccines at pharmacies, placing extra pressure on pharmacists.
“It is possible for a patient to walk in seeking their vaccination while their phone is ringing nonstop, prescriptions need to be filled, and people are waiting in line,” said Jew.
Instead of attempting to distribute drugs at the same time, the Institute for Safe Medication Practices advises pharmacists to set aside certain times to deliver vaccinations.
It also includes some advice for patients on how to lessen the possibility of drug mistakes. People should first learn the brand and generic names of their drugs, as well as the recommended doses and methods for taking them. From there, they may verify the information is accurate by looking at the labels of the medications.
Additionally, the institution advises taking a duplicate of your prescription to the drugstore. Consult a pharmacist to review the prescribed information if the medicine is new. The majority of prescription labels will explain how the drug looks, so you can make sure the description matches the contents of the box.
Jew said, “The color, shade, and any imprints on these tablets or capsules should be described somewhere on the label.” “It’s crucial to double-check that step.”
Lastly, the institution advises filling prescriptions at the same drugstore. Because of this, pharmacists will find it simpler to identify any possible medication interactions or allergies based on your medical history.
NEWS COLLECTED : NBC NEWS
