got my dd. caitlins seizure meds today but....(update post 15)

[beckyand3littlemonsters]

.....they put the wrong dosage on the label the right dosage for a child of caitlin's age is 0.5ml they have prescribed her 2.5ml thats 5x the amount i have 2 boxes one for home and one that will be staying at school, i dread to even think what would happen had i not noticed and sent it to school if she had a seizure she would be overdosed. i phoned the dr. who prescribed the meeds and he has told me to go back to the chemist and get them to change the labels as this is the only problem and he has given me his work mobile number incase they won't change it without talking to him first. It is the pharmacist that has messed this up the dr. prescribed her 5mg which the meds are 10mg/1ml so that would be right. am i over reacting to be so mad, i can't help thinking of the what if's

[CarrieMF]

I could see possibly being upset, but I wouldn't be overly mad about it either. If this was a new med(or a change, or a RX rewal on paper) & the pharmacist was reading a RX it is very easy to get things mixed up. This is why you're always supposed to check a RX before leaving.

Do you have to fill out a medical form for the school to administer meds? If so you most likely would have caught it then. If it was something they were already giving her or had instructions for & they noticed it on the bottle that it was different I"m sure they would have called for verification on what to do.

[Bea]

You're totally not wrong to be furious. I would be too and wouldn't be meek when I return it to the pharmacy to be relabelled.

Unfortunately, as an RN dealing with both hospital in facility based pharmacies and nursing home's outwith facility pharmacies, you'd be horrified how often these types of errors happen.

Demand action! This can't be simply brushed off as a harmless human error. This could have resulted in a fatality

Thank goodness you were vigilant.

[2boyzmama]

Originally Posted by Bea

You're totally not wrong to be furious. I would be too and wouldn't be meek when I return it to the pharmacy to be relabelled.

Unfortunately, as an RN dealing with both hospital in facility based pharmacies and nursing home's outwith facility pharmacies, you'd be horrified how often these types of errors happen.

Demand action! This can't be simply brushed off as a harmless human error. This could have resulted in a fatality

Thank goodness you were vigilant.

YES!!! I'm not saying sue the pants off of them, because thankfully you were vigilant and you did notice the error, and she is okay. BUT they need to review their quality processes to ensure that thsi doesn't happen again!!

My younger sister ended up hospitalized after an issue with a medication filled at a pharmacy, and when my mom complained, she didn't get a good response from them. So she called the licensing board and it turned out that there had been many complaints about "small" mixups, but my sister's issue was the last straw, and that pharmacy actually was shut down a month later (and it was a chain, too! Only that location was shut down, not the whole chain, and it did reopen a few months later after they re-hauled everything).

So get it fixed, and make sure that the store knows, and possibly consider reporting it to the licensing board.

[SpottedFoxx]

I'd be upset too but this is a VERY common occurrence. My brother's pediatrician ordered a sea sick patch for him. He put it on and went deep sea fishing with my father. Turns out they gave him a nitro patch. Deep sea charters never turn around unless someone is on death's door. The boat turned around - my brother's blood pressure kept dropping tremendously. My Mom had woke up and seen the label and called the coast guard who radioed the boat to have them remove the patch.

This is a valuable lesson to all. ALWAYS read you and your child's prescriptions before leaving the office. Know the correct dosage. Read the labels before you leave.

Also, as an aside, when getting tests done to your child or yourself, always request a copy of the results be sent to you (blood, radiology, etc). I've been told that my blood work was normal, gotten the lab results only to find my levels were off the chart.

[beckyand3littlemonsters]

Got it changed, her dose is 0.25 ml so it was actually 10x too much
i'm going to see the prescriptions manager tomorrow to see what happened i know it must be easily done 2.5mg and 2.5 ml look similar but it could have been really bad. i think something does need to be done i wouldn't sue but just thinking how something as simple as the difference between g and l could have disastrous consequences.
i'm actually just a bit confused why she is on a dosage meant for 6-12mths though should i be concerned?

[SpottedFoxx]

My son was on seizure meds from 5-14 months. The dosage is weight, not age based. Because of the seizures he was having, they let him grow out of his dosage (meaning they didn't raise it as he got bigger).

Originally Posted by beckyand3littlemonsters

Got it changed, her dose is 0.25 ml so it was actually 10x too much
i'm going to see the prescriptions manager tomorrow to see what happened i know it must be easily done 2.5mg and 2.5 ml look similar but it could have been really bad. i think something does need to be done i wouldn't sue but just thinking how something as simple as the difference between g and l could have disastrous consequences.
i'm actually just a bit confused why she is on a dosage meant for 6-12mths though should i be concerned?

[CarrieMF]

could it be a med that they need to start slowly & increase if the lower doses don't work?

[beckyand3littlemonsters]

Originally Posted by SpottedFoxx

My son was on seizure meds from 5-14 months. The dosage is weight, not age based. Because of the seizures he was having, they let him grow out of his dosage (meaning they didn't raise it as he got bigger).

yeah i know it's not age based but i still thought she would be in the 1-4 yr. range even going by weight because even though she is small for her age she's not that small, iykwim.

Originally Posted by CarrieMF

could it be a med that they need to start slowly & increase if the lower doses don't work?

it could well be, i'm hoping cos she's on twice daily epilepsy meds she will never need it anyway as this medicine is only used if she actually has a seizure.

[CarrieMF]

ah, then it could be with the comination of regular epilepsy meds & this one(if needed) would be enough. If it was JUST this other med then she'd probably be on a higher dose.

[beckyand3littlemonsters]

Originally Posted by CarrieMF

ah, then it could be with the comination of regular epilepsy meds & this one(if needed) would be enough. If it was JUST this other med then she'd probably be on a higher dose.

never actually thought of that but it does make sense.

i'm going to see the manager this afternoon, i can't help thinking how bad this could have been also i don't know if this is a good example or not but what if they had a patient who was recently diagnosed with insulin dependant diabetes and made this same mistake.

[beckyand3littlemonsters]

I went today but the manager wasn't there and won't be until tuesday because it's not open at the weekend and monday is a bank holiday. The lady spoke to was very apologetic though and said she let her manager know i'll be going to speak to her on tuesday.

[Cinder]

Originally Posted by CarrieMF

I could see possibly being upset, but I wouldn't be overly mad about it either. If this was a new med(or a change, or a RX rewal on paper) & the pharmacist was reading a RX it is very easy to get things mixed up. This is why you're always supposed to check a RX before leaving.

Do you have to fill out a medical form for the school to administer meds? If so you most likely would have caught it then. If it was something they were already giving her or had instructions for & they noticed it on the bottle that it was different I"m sure they would have called for verification on what to do.

I agree, I think it's great you caught it, but I don't think it is fair to be mad at the pharmacist...everyone, every one!, makes mistakes in their job...no matter how important you can't expect anyone to be perfect. Neither our GP or our Ped will write scripts anymore, they call them in or do them online depending on your pharmacy, less room for error since the pharmacist isn't trying to read the doctor's writing, which can be difficult at times.

[beckyand3littlemonsters]

Originally Posted by Cinder

I agree, I think it's great you caught it, but I don't think it is fair to be mad at the pharmacist...everyone, every one!, makes mistakes in their job...no matter how important you can't expect anyone to be perfect. Neither our GP or our Ped will write scripts anymore, they call them in or do them online depending on your pharmacy, less room for error since the pharmacist isn't trying to read the doctor's writing, which can be difficult at times.

It wasn't hand written it was printed, i haven't gone all mad with them but i am angry and i know people do make mistakes but when dealing with things this important more care needs to be taken to insure mistakes don't happen it's not like i'm talking about going to mc donalds and getting too much ice in a drink where talking about prescribing 10x the amount of medicine, people could die from these mistakes.

[beckyand3littlemonsters]

I went and spoke to the pharmacist who did caitlin's prescription and she was really nice said how she understood why i was upset and that she was really sorry and that she would make sure that everyone double checked everything from now on even when understaffed, she said had it been her she would have done the same and she was glad i noticed it and went in and that if i have any concerns about anything i can speak to her. so as this does seem to be a one off incident i've decided it's probably best to go no further.
thanks to everyone who replied.