Big prescription label error shakes up Bountiful mom

Becky Vanderlinden was surprised last week when she looked at the dose instructions on the bottle of antibiotics for her toddler.

"I thought, 'This seems like a huge amount of medicine for a baby,"' says Vanderlinden, who immediately called the pharmacy to double-check. "The gentleman I spoke with said, 'This is the right dose."'

So, she gave 19-month-old Lily the 2 1/2 teaspoons of Omnicef and repeated the dose three more times. At that point the bottle was empty, so Vanderlinden called the pharmacy back. That's when she discovered that her original suspicions were right. It turned out the dose on the label was five times the amount the doctor had prescribed.

By then, Lily had severe diarrhea, and a couple of days later had developed a painful yeast infection. The whole episode has left the Bountiful mom a bit shaken — and with advice for other parents and patients: If something raises a red flag, trust your instincts. Don't be afraid to question.

According to a study conducted in 2002 by researchers at Auburn University, "errors associated with dispensing prescriptions are committed every day in pharmacies around the country." The study found that 1.6 percent of a sampling of prescriptions filled at community pharmacies in six randomly selected cities contained some type of error.

The errors included dispensing an incorrect drug, an incorrect form or incorrect amount, and labelling errors such as printing incorrect doses or instructions. The error rates were slightly higher for independent pharmacies than chain stores or health system pharmacies.

Occasionally the errors result in deaths or severe injury. In 2004, a Cook County jury awarded $21 million to an Illinois family whose daughter had permanent brain injuries the family alleged resulted when a pharmacy filled her prescription for anti-seizure medication with an adult diabetes drug.

Neither the Utah Department of Health nor The Utah Division of Occupational and Professional Licensing, which regulates pharmacists, keeps statistics on pharmacy errors. Like most states in the country, Utah does not require pharmacies to report those errors.

According to Utah Poison Control Center director Barbara Crouch, prescription errors that end up as calls to the center "happen very infrequently but do occur." The center has studied what it calls "10-fold errors" (doses that are 10 times more or less than the doctor ordered) in children younger than 6 years old and found that there were 29 calls (but these could have been either the fault of the pharmacy, the prescriber or the parent, Crouch pointed out).