A North Carolina mother reported that her daughter fell sick due to a pharmacy error, receiving an incorrect dosage of liquid medication for ADHD (attention deficit hyperactivity disorder). Consequently, the concerned mum filed a complaint with the North Carolina Board of Pharmacy.
This was after discovering that a pharmacist gave her 5-year-old daughter five daily milliliters of Quillivant XR instead of the doctor-recommended one daily milliliter. On February 4, 2024, NBC affiliate WXII reported the incident in Winston-Salem, North Carolina.
However, despite requests for comment, the North Carolina agency has yet to respond. The mother revealed that they admitted her daughter to the emergency room due to adverse effects. Notably, Quillivant XR is for individuals aged six and older.
The mother reported the error to Walgreens, where a pharmacist acknowledged misreading the prescription and said the rush cause was limited staffing. However, Walgreens informed NBC News that it cannot comment on some instances due to patient confidentiality laws.
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In a statement, the company emphasized its concern for the well-being of patients during any prescription error. Furthermore, Walgreens noted its multi-step procedure, including several safety checks to reduce human error.
Walgreens continued, “We have reviewed this process with our pharmacy staff to prevent such occurrences.” Notably, the Food and Drug Administration (FDA) receives over 100,000 annual reports of medication errors.
This includes preventable incidents like prescribing incorrect dosages that can harm patients or result in drug misuse. A recent study revealed that 7,000 to 9,000 US residents succumb to medication errors annually.
This excludes the hundreds of thousands experiencing unreported adverse complications or reactions. “Potential dosing errors are likely common,” says Adam Bursa, a University of Illinois Chicago clinical assistant professor.
According to Bursa, liquid medications are susceptible to dosing errors. This is often due to the use of milligrams or millimeters in prescriptions. Bursa emphasized that there will always be errors whenever humans are involved in transcription, calculations, or typing.
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Moreover, Rita Jew, President of The Institute for Safe Medication Practices, also gave her two cents. She mentioned that the lack of similar electronic systems among pharmacies and doctors’ offices contributes to the issue.
Confirmation bias is another factor contributing to dosing errors. Jew pointed out that pharmacies often lack crucial patient information, including weight, age, etc. Thus, it becomes a problem to identify incorrect dosages.
Responding to this, the Institute for Safe Medication Practices suggests that pharmacies allocate time to prescribe vaccines. The institution insists that the process must be different from the process of dispensing other medications.
Additionally, they suggest patients learn their medications’ generic and brand names and understand the correct dosage instructions. Finally, Jew emphasized the importance of checking medication labels thoroughly.
She said, “Somewhere on the label, it should describe the color, the shade, and any imprints on these tablets or capsules.” Likewise, the institute recommends consistently using the same pharmacy for medication refills.
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