4-year-old 'acting like a slobbering drunk' after pharmacy dispenses wrong dose of antipsychotic drug

The mother of a four-year-old boy is left with a lot of questions after a Shoppers Drug Mart pharmacy messed up her son's prescription, giving the boy 10 times the correct dose of an antipsychotic drug over a period of several months.

"I'm very angry that this has happened," Sherrie Jackson-Buller told Go Public.

"These people are dealing with life-altering medications, this had serious repercussions from my son. He suffered for months."

Jackson-Buller's four-year-old son, Adam, suffers from ADHD and other behavioural problems.

The boy's doctor faxed a prescription to the Westgate Plaza Shoppers Drug Mart in Saskatoon.

The prescription was for a 0.3 ml dose of the liquid form of a drug called Risperidone, often used to treat mental or emotional disorders.

Instead, the pharmacy dispensed three millilitres to the boy: 10 times what was prescribed. The overdose went unchecked and undetected for months with each refill.

"The first time we gave Adam the dosage, about 30 minutes after, he was acting like a slobbering drunk. He couldn't stand up, he was drooling, he couldn't walk on his own. We had to carry him," Jackson-Buller said.

Jackson-Buller consulted her doctor, who told her the issues could be a side effect from the medication and would wear off.

Another doctor at a clinic thought Adam had a virus. But weeks passed and Adam's condition got worse.

Long-term damage feared

The error was finally discovered by accident four months later when Jackson-Buller again called one of Adam's doctors to say the side effects had not gone away and Adam was still feeling sick.

"She said, 'Let's up the dose, how much is Adam receiving?' I pulled out the Risperidone bottle and said he's receiving 3 millilitres. She said to me, 'No, no that's too much, he should not be receiving that amount, it's too high for a child his age.'"

Adam's mother says she's concerned the excessive dose may have caused damage to the boy's kidneys and liver, and that he will need to be tested repeatedly over the next five years to make sure there is no long-term damage.

Shoppers says incident an 'unfortunate error'

The owner of the Saskatoon pharmacy would not answer our questions, but Shoppers Drug Mart, which is owned by Loblaw Companies, sent written statements saying the error was an isolated incident.

"In this case, an unfortunate error was made and the patient received an unintended dosage of prescribed medication," said Tammy Smitham, vice-president of external communications.

"In seeking resolution, the associate-owner of the Shoppers Drug Mart pharmacy held follow-up conversations with the patient's mother and doctor. We have provided context and apologies in person and through our company customer service team," said Smitham.

"We continue to express our sympathy and we are, as we speak, engaged with the customer to help find a suitable resolution to her concerns."

Smitham also says Shoppers has reviewed the situation with the pharmacy team to make sure the appropriate protocols are in place.

Pharmacy provides incomplete medication record

Jackson-Buller tried to document the mistake, asking the pharmacy's manager for a medication history report for her son. She says she had to wait several days for the printout. When she got it, it was lacking information on the overdoses.

Two of the three refills with the incorrect dose were missing from the report.

She went back weeks later and requested another copy of the same report from a different employee. That medication history shows the complete record.

When Go Public asked how that happened, Shoppers said, "the variation in the print outs of medication history, was the result of an isolated IT issue."

No accountability, says mom

Sherrie Jackson-Buller says the owner of the pharmacy responsible apologized, saying the pharmacy misread the handwritten prescription and that while two of the pharmacists working that day questioned the dose, no one called Adam's doctor to check.

Jackson-Buller says she couldn't get anyone from Shoppers Drug Mart's head office to address the issue.

"Nobody from Shoppers would talk to me, [the pharmacy owner] said someone from Shoppers would get back to me, nothing happened, nobody called," she said.

It wasn't until after she contacted Go Public that Shoppers contacted Jackson-Buller and began the process of negotiating compensation.

Jackson-Buller has hired a lawyer and says she won't settle until she knows if there will be a long-term impact on her son's health.

There are also questions about how Adam's pediatrician wrote the prescription. 

The Institute for Safe Medication Practices (ISMP) has a list of abbreviations doctors should avoid. It includes using a decimal point without a zero in front. ISMP warns this practice could lead to 10-fold dose errors like the one Adam experienced. 

Adam's doctor didn't immediately return our calls.

Canadians in the dark about prescription errors

Go Public wanted to know if this pharmacy had a history of prescription errors, but found Canadians have no access to that information.

Our investigation found there is no mandatory disclosure of medication errors to a public body and no national tracking system monitoring how often errors happen.

With the exception of Nova Scotia, Canada relies on several voluntary systems, some national, some provincial.

"We should be looking at the numbers, but it is difficult to get because every province has its own health system, every organization does something a little bit differently, " said Chris Power of the Canadian Patient Safety Institute (CPSI).

Most of the provincial organizations that oversee pharmacists require retail pharmacies to track and address errors within the company.

Pharmacists are not required to disclose that information to any public or governing body unless the governing College does a spot check.

In some provinces, those inspections only happen every six years and even then, the results are not public.

Power says the implications of medication errors affect everyone, leading to increased readmission rates to hospitals and longer stays at a greater cost to taxpayers.

"I think there does need to be increased transparency... If we compare that to the aviation industry, when errors are made around the world, errors of significance, it's known almost immediately and changes are made immediately," said Power.

"In the health care system, we don't do that … sometimes we don't even share within provinces when those issues happen, so it's really difficult for us to put in those processes to make sure it doesn't happen again."

The limited statistics available are collected, in part, by the Institute for Safe Medication Practices (ISMP) Canada, which show that from August 2006 to September 2016, almost 1,300 incident reports were received from concerned reporters in retail pharmacies.

Of those, 900 were designated "no harm" incidents, and 115 were "harm" incidents where six resulted in serious harm (none in death).

Of the six serious incidents, two were incorrect doses.

ISMP Canada also says because those numbers are based on a voluntary reporting, there is no way to know the error rate.

Shoppers Drug Mart has its own incident reporting procedure and says the "reports are taken very seriously."

But as is the case for most pharmacies in Canada, those reports are not public.

Canadian patient safety week begins October 24.

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