Medication Error in NC Leaves 5-Year-Old Life at Risk

A North Carolina mother reported a pharmacy error that left her 5-year-old daughter sickened due to receiving an incorrect dosage of medication prescribed for attention-deficit/hyperactivity disorder (ADHD). The incident highlights the serious risks associated with improper dosing of ADHD medications like Quillivant XR.

According to the mother, her daughter was prescribed 1 daily milliliter of Quillivant XR but instead was given 5 daily milliliters, a dosage five times higher than recommended by her doctor. Concerned for her daughter’s safety, the mother filed a complaint with the North Carolina Board of Pharmacy. The board has since confirmed receiving the complaint.

The child experienced significant side effects from the overdose and was admitted to the emergency room. The mother explained that her daughter, who is underweight for her age, was prescribed Quillivant XR off-label. While the medication is approved for children aged 6 and older, starting at 4 milliliters per dose, deviations for younger or smaller patients require extreme caution.

The error occurred at a Walgreens pharmacy. The mother reported that a pharmacist admitted to misreading the order while rushing due to limited staffing. In a statement to NBC News, Walgreens declined to discuss specific cases, citing confidentiality laws, but emphasized their commitment to patient safety:

“In the event of any prescription error, our first concern is always for a patient’s well-being. Our multi-step procedure includes several safety checks to minimize the chance of human error, and we have reviewed this process with our pharmacy staff in order to prevent such occurrences.”

Medication errors, including those involving ADHD medications, are a significant public health concern. The Food and Drug Administration (FDA) receives over 100,000 reports annually of preventable medication errors that could harm patients. Research published last year revealed that 7,000 to 9,000 people in the U.S. die each year due to such errors, with many more experiencing adverse reactions or complications.

Experts say liquid medications are particularly prone to dosing errors. Adam Bursua, a clinical assistant professor at the University of Illinois Chicago College of Pharmacy, explained:

“Any time humans are involved with transcribing or having to type or calculate on their own, it introduces a new opportunity for human error to sneak in.”

Liquid medications, like Quillivant XR, are dosed based on weight in either kilograms or pounds, requiring accurate calculations and conversions. Errors can occur during transcription or when pharmacists manually input prescriptions into their systems.

Rita Jew, president of the Institute for Safe Medication Practices, noted that a lack of integration between doctors’ offices and pharmacy electronic systems exacerbates the issue.

“Sometimes the prescription will be dumped into miscellaneous fields, and the pharmacist will have to re-input it manually,” she explained.

Pharmacists often work with limited patient information, such as age and weight, making it difficult to identify potentially incorrect dosages. Compounding the issue is the heavy workload pharmacy staff face. A 2019 survey by the Department of Health and Human Services found that interruptions and time pressures in pharmacies contribute to errors.

The Covid-19 pandemic further strained pharmacy staff, as vaccination demands increased significantly. Jew noted,

“You can have a patient walk in and want their vaccine when your phone is ringing off the hook and you have prescriptions waiting to be filled and you have people standing in line.”

The Institute for Safe Medication Practices offers several recommendations to reduce medication errors:

1. Understand Your Medications: Know both the generic and brand names, the correct dosage, and how to take them.
2. Verify the Prescription: Check the medication label for accuracy, ensuring it matches your doctor’s instructions. If possible, bring a copy of the prescription for comparison.
3. Examine the Medication: Look for a description of the medication’s appearance on the label and verify that it matches what’s inside the container.
4. Use a Single Pharmacy: Filling prescriptions at the same location helps pharmacists maintain a complete history of medications and flag potential interactions or allergies.
5. Ask Questions: When picking up new prescriptions, speak to a pharmacist to review the dosage and instructions.

Jew emphasized the importance of double-checking medication labels:

“Somewhere on the label, it should describe the color, the shade and any imprints on these tablets or capsules. That’s a very important step to double-check.”

Additionally, the Institute advises pharmacies to dedicate specific times for vaccinations to reduce distractions during medication dispensing.

The North Carolina incident underscores the critical need for robust safety protocols in pharmacies, particularly for medications like Quillivant XR that require precise dosing. ADHD medications can have serious side effects if not administered correctly, making vigilance essential.

For parents and caregivers, understanding how to advocate for accurate prescriptions and verifying medication details can serve as vital safeguards against pharmacy errors. As this case demonstrates, even a small mistake can lead to significant health risks.