A mother recently called my office about a prescription error by one of the major national pharmacy chains.
She explained that her young son was having some depression issues, so she made an appointment with his pediatrician. The doctor wrote a prescription for Aripiprazole (also known under the brand name Abilify), an anti-depression medication, for dosage of 2 mg per day.
Aripiprazole is an antipsychotic medication typically used to treat schizophrenia and bipolar disorder. Some providers also use it to treat major depressive disorder. Side effects of the medication include neurologic and movement disorders.
The family took the prescription to a pharmacy near their home in northwest Houston. Instead of dispensing the prescription for 2 mg per day, the pharmacist filled the Aripiprazole prescription for 30 mg day. That is 15 times the dosage that had been prescribed!
After the boy started taking the medication, his mother noticed that he was very tired, falling into a deep sleep, and in a sort-of daze throughout the day. She called the pediatrician, who recommend giving it to him before bedtime instead of the morning. When that did not help, she gave the medicine to her son every other day.
The mom made another appointment with her son’s pediatrician to request a new medication altogether. Before that appointment, though, the pharmacy called to inform her of their mistake.
It is currently too soon to see if this young man will have any permanent injuries because of the pharmacies overdose. The medical literature reflects that Aripiprazole/Abilify overdoses can cause central nervous system depression ranging from mild sedation to coma.
What you can do
When considering the major pharmacies have computer warning systems that should prevent accidental dosage errors like this, it surprises me that this happened. Starting a pediatric patient on a new Aripiprazole prescription for 30 mg per day is well beyond the manufacturer’s recommended dosage.
In addition, it is also surprising that the pharmacist did not catch this significant error because, as a new prescription, Texas law required the pharmacist to counsel the patient on the medication.
Even with these protective mechanisms in place, medical errors still happen. You can help improve your patient safety by doing a few things on your own.
Any time that a doctor, physician assistant, or nurse practitioner writes a new prescription, ask for a printed copy of it. Healthcare providers frequently send prescriptions directly to the pharmacy electronically or may call them in. Take your printed copy of the prescription to the pharmacy and compare the medication name and dosage to what the pharmacist dispenses to you.
Be sure to take advantage of receiving counseling from the pharmacist, when offered. There is no cost for this counseling, and it gives you an opportunity to ask the pharmacist any questions, including verification of the drug name and dosage. I also recommend asking your pharmacist if a new medication has warnings or contraindications for use with any particular medical conditions or other prescription drugs.
We are here to help
If you or someone you love has been seriously injured by a medication, prescription, or pharmacy error, our experienced medical negligence attorneys can help. Click here to send us a confidential email via our “Contact Us” form or call us at 281-580-8800.
All consultations are free and, because we only represent clients on a contingency fee, you will owe us nothing unless we win your case.
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Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. In 2017, H Texas magazine named him one of Houston’s top lawyers. In May 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.
