Right Medication, Wrong Instructions Lead to Patient’s Death

December 21, 2018
Ann W. Latner, JD

Providing the right medication to the right patient is one of the most important duties of a pharmacist. Much has been written about cases where a patient was given the wrong medication or given someone else’s medication, resulting in a bad or even tragic outcome. But even when the medication is properly dispensed, if the instructions are wrong a bad outcome can easily happen, as it did in this month’s case.

Just the Facts

The patient, Mr. S, was a 46-year old roofer living in Florida. He suffered from neuropathy, which caused great pain in his legs and back. His physician had prescribed Oxycontin and Neurontin, but the patient was unhappy with the mental fuzziness that the medications caused and requested something else. In response, his physician switched Mr. S to 10-milligram methadone tablets. The instructions on the prescription were for the patient to take two tablets, two times a day (a total of four pills daily).

Mr. S took the prescription to his local pharmacy, a national chain. The pharmacy was staffed with an extremely busy pharmacist, and two pharmacy technicians. One tech was typing up prescription labels and filling prescriptions, one was assisting customers, and the pharmacist was giving flu shots, counseling patients, and checking the prescriptions that the tech filled before they were handed to patients.

A pharmacy tech incorrectly typed the instructions on the label of Mr. S’s prescription. Instead of “take two tablets, twice a day” the instructions read “take two tablets, as needed for chronic pain.” The pharmacist, who was trying to do several things simultaneously, verified that the medication in the vial was correct, but he neglected to check the instructions.

Mr. S returned home with his medication. His pain was intense, so he took the two-pill dose. It didn’t seem to help much, so a couple of hours later he took two more, and then, again, a few hours after that. Over the course of a day and a half, Mr. S took at least 22 pills. After Mr. S’s wife went to sleep, Mr. S went into the bathroom, which is where he was found, dead, the following morning.

Initially, Mr. S’s death was ruled a heart attack, and no autopsy was performed, but two months later his wife was able to convince the county medical examiner to exhume the body based on the fact that he had recently started taking methadone. The autopsy revealed that Mr. S died of methadone toxicity.

Mrs. S hired an attorney who discovered the discrepancy between the wording on the pill bottle and the original prescription and sued the pharmacy.

Case Settles Before Trial

During the discovery portion of the case, when records and information are subpoenaed, and depositions are taken, more evidence emerged. Mrs. S recalled that when the prescription was picked up at the pharmacy’s drive-through window, the employee’s question to her husband was framed in the negative – “you don’t have any questions for the pharmacist, do you?” It also turned out that the instructions had been incorrectly typed in by a part-time 22-year-old pharmacy tech, and that the pharmacist on duty that day was dealing with an extremely heavy workload.

After discovery, and an unsuccessful motion to have the case dismissed, the pharmacy decided to settle the case out of court, with a confidentiality agreement barring disclosure of the exact terms.

The Takeaway

Getting the medication right is vital. Making sure that the medication is going to the right patient is also vital. But equally important is ensuring that a prescription’s instructions are correct on the patient’s pill bottle and in written and oral advice given to the patient. Patients rely on the information on their prescription bottle, and the instructions given by their pharmacist, and these instructions must be verified.

Train staff to double check instructions as well as dosages and dispensing of the correct medication. Have safeguards in place to verify that instructions on the bottle match the original prescription. This case illustrates how what is on the outside of the pill bottle can be as important as what is on the inside.