Jessie Scott, an 18-year-old from Draper, Utah has been in a coma since the end of April because of a critical error which occurred at a Walmart pharmacy. His doctor prescribed Jessie 5mg of Oxycodone Hydrochoride in a liquid solution to help him with the severe pain of his strep throat, however, what he received from the pharmacy was a concentrated solution which was supposed to have been diluted before being dispensed to Jessie. Exactly how much medication did Jessie consume?
He consumed 1 teaspoon measured in a medicine cup which in its concentrated state contained 20 times the prescribed dose (100mg) and within hours, his organs began to fail and had to be placed on a ventilator.
The KSLTV article says,
Laurie Scott said, “This shouldn’t have happened. It was needless. It was senseless and it’s changed lives forever, not just Jessie, but there are other people who love him and his future.”
Laurie trusted what she gave her son, what had been filled, was correct.
“I always ask questions. I’ve always medicated him his whole life. I’m the caregiver and it makes it extremely difficult,” she said.
After 16 days in ICU, Jessie moved to intermediate care for another four days, then to HealthSouth for intensive therapy.
Wal-Mart Corporation issued the following statement to KSL News: “This is a very sad situation. Our thoughts are with this young man and his family.”
There was a dramatic turn of events this weekend. For the first time, Jessie spoke, though the words are limited and intermittent. We will continue following his story in the weeks and months to come.
What makes this even more infuriating is that pharmacists receive extensive specialized training to prevent these exact types of situations. We are supposed to be able to trust that the medication the pharmacy prepares won’t kill us, or worse. We are, however, shocked that Walmart seems to actually be acknowledging the error–they usually deny everything until the point of absurdity. Our thoughts are with the Scott family, we hope that Jessie gets better soon.
Teen in coma after wrong dose of medication [KSLTV] (Thanks to Seth!)
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@StupidDufus:
I agree. You talk about mistakes made in a medical environment, researchers, lab techs, nurses, humans, etc. make mistakes. Not everyday, but let’s say you have a 99.9% success rate with your dilutions and you do 10,000 samples a month. You just sent the wrong results for 10 people and now they may be on improper treatments that could be life threatening.
They go to school to prevent this kind of stuff from happening. In fact, anyone who takes chem 101 should be able to dilute something properly, but sometimes stuff happens and instead of adding 90mL you add 9mL because you dropped a 0 somewhere.
Yeah, it’s not uncommon for kids to be prescribed oxycodone or other pain drops when their strep throats get so severe that they have trouble swallowing food. Kids’ tolerance for that kind of pain is much lower than an adults, and their condition can turn south from not eating just as quickly.
That being said, there really is no excuse for this, which is why Walmart is taking responsibility. This sort of thing is exactly why pharmacists have to go through so much training and schooling.
Good God.
Although I realize that these things can and do happen, I also know, at least in my neck of the woods, that the Wallyworld pharmacy messes up continuously and has a couple of pill thieves in their midst. I ended up transferring all of my prescriptions when my vicodin refill was 10 pills short. I went up the food chain about it, but nobody did anything.
I sent this story to my husband and his response was, “You are never getting medication from WalMart again”. Yea, I got no prob with that, that’s for sure.
I was a pharmacy tech for 5 years, and here are the questions and comments I have:
A) The last time I checked, we NEVER mixed Oxycodone concentrate. You NEVER opened a sealed bottle that was intended for one patient. It came in a 30 ml bottle and the doctor was supposed to take into account that it was concentrate and dose accordingly. So the doctor could have been at fault, unless the tech who entered the order messed up the sig information (dosing).
B) I know people who work at a Wal-Mart pharmacy, and the pharmacy techs, certified or not, were never allowed to touch Controlled Substances or Narcotics. Only the pharmacist filled and dispensed those. So it wasn’t a tech. Unfortunately, many people are right. Retail pharmacy is awful and the pharmacists hardly get any help, so they are stressed out and overworked. 12 hour shifts for pharmacists should be banned, considering that they are working straight through those 12 hours and hardly get any breaks.
C) Pharmacists are HIGHLY qualified. It sounds like most people don’t know this, but pharmacists coming out of school right now are considered doctors. They get their doctorate, so they ARE doctors. The technical term for them is Doctor of Pharmacy. They take an 8 year degree and cram it down to 6 years of schooling, but they go year round at 21 credit hours for most semesters. So stating that most pharmacists are idiots and that they would trust a doctor with medicine more is ludicrous. Their entire degree is about drugs, their chemical compounds, interactions, etc. Doctors are qualified, I’m not saying that, but as far as I knew, they only spend a semester or two on pharmacology. Yes, pharmacists are over worked and make mistakes, but doctors are in the exact same boat.
4. If anyone is worried about whether or not they received the right pill (since there are so many different kind of generics of so many drugs), you should refer to this database and it will give you the color and numbers on the pill you seek: [www.drugs.com]
I hope this boy ends up being okay, though. Oxycodone is serious business and truthfully, I wouldn’t take it unless I was on my deathbed. I will pray for him.
Yeah I saw this on the news last night…its really sad.
From the video I saw the boy appears completely and totally mentally damaged.
Very sad indeed. But this could truly happen anywhere, it’s not a WalMart thing. In the past few years some of the most egregious medical errors on record have come out of the oh-so-esteemed Duke University Medical Center.
@Red_Eye: Hospitals aren’t immune from making the same mistake. Dennis Quaid’s twins are a recent, high-profile example: [www.cbsnews.com]
And why do you keep going back to the same pharmacist/pharmacy if they keep on making the same mistake?
“opsomath”
Your wife was prescribed the hydrocodone for her cough because it is a powerful antitussive. Same reason as many prescription cough syrups contain codeine, another narcotic.
@Cliff_Donner:A very perceptive comment. An insider will tell you there is a mistake response protocol for retail pharmacists that includes specific comments and behaviors all of which acknowledge the circumstance but do not admit blame nor accept responsibility. As for the 1.0mg being misread as 10mg, this was a multi-million dollar Walgreens mistake regarding Coumadin. Unfortunately, it comes in one and ten mg strengths. Hospital Rx orders can never include trailing zeros. It’s a JCAHO violation.
@temporaryerror: Thanks for the clarification – I guess Wikipedia’s out of date.
Hopefully after reading this article’s comments I won’t catch any of you dropping off prescriptions at the pharmacy I work at and yelling at me when I tell you our wait time is a (very reasonable) hour. Especially if it’s a refill. Even more especially if it’s a refill of a maintenance medication. Pharmacies go to bigger volume, lower prices, and faster service because that is what the demand is. I’m constantly being told X drug is cheaper somewhere else, or X pharmacy never makes them wait. It’s up to the pharmacist to make sure that the people around him/her don’t pressure him/her into working in a manner that is unsafe. Pharmacists have a very important job making sure everyone’s drugs are correct (because of this they are compensated well.) But of course, everyone makes mistakes.
Having said that, this is a mistake that should not happen regardless. I feel bad for all parties involved.
As a former pharmacy tech, I’ve gotta take umbrage with some of the comments directed at pharmacy technicians. In the back of your pharmacy, no matter if it’s Walmart or the corner drug store, you have three different classes of people working. You have your pharmacy cashiers, who are not very well trained as far as drugs go but know everything there is to know about privacy laws, etc. as well as insurance – they simply ring up your “purchase.”
The second tier is your pharmacy technicians. Pharmacy techs are almost without fail certified, in most cases by a group called the Pharmacy Technician Certification Board. I can say from personal experience that the exam that they put out for certification is by no means a cake walk – you definitely need to know your stuff in order to pass it. For an hourly job, they’re paid surprisingly well. I worked at Walgreens and as a tech I got paid in the range of $10-$12 an hour.
The third, top tier is, of course, your pharmacists. They have a substantial amount of training and schooling. Are they perfect? No, of course not. But they don’t make “reckless” mistakes like some commenters have suggested. Also, EVERYTHING that a pharmacy tech does is double checked by a pharmacist, and pharmacists double-check their own work. They’re not simply churning out ‘scrips with no regard for anyone else, they’re being as careful as they can. Unfortunately, mistakes happen.
While Pharmacists are supposed to check everything, they don’t fill all prescriptions. Depending on the State, you don’t even need a certification to be a pharmacy technician. It is likely a young, equally aged pharmacy technician filled the prescription incorrectly. I was a pharm tech at 18 and had no training. I almost made the equal mistake once but it was caught by the pharmacist. What makes it worse is doctors hand writing is horrible. So mistakes occur in medicine that has similar sounding names.
@JackWalker: I think a lot of people here are confusing Oxycodone with Oxycontin aka hillbilly heroin.
And, just for the record for everyone else, all painkillers are not created equal, nor are they all dispensed at “Confessions of an Opium Eater” levels. And they work differently, as well. Take for example my blood cancer. You can’t take NSAIDs b/c of the risk of thrombocytopenia (way to few platelets leading to severe bleeding) so they prescribe you opioids. Well opioids don’t do half a good damn, because the pain is in your joints from what-the-hell-ever. Mostly I would just forget that I was hurting after taking my Percocet, but as far as actually relieving the pain, I needed the NSAIDs, and would occasionally break down and take a freaking Ibuprofen just to get some relief. Obviously this kid needed something different.
This is a disturbing trend in the pharmaceutical industry. These super chains, Walmart, Walgreens, Duane Reade, etc., are cutting costs by cutting the quality of care for customers. I miss the days of the small pharmacies that gave personal care, and true compassion for the people who dispensed pescriptions to. Now, we’re usually at the mercy of some young kid who doesnt know jack about any side effects, interactions, or instructions on these strong medications.
While traveling this spring, I had a throat so sore that I ended up
in a NJ ER at 6 AM on Easter Sunday. And I don’t go to the ER. Ever.
I couldn’t talk, or swallow, and basically was drooling into a towel.
So yeh, Strep can hurt pretty bad. 1000 mg of Motrin and a bottle of
throat wash barely made a dent in the pain. On another note, my heart
goes out to this child.
Hesfsu
While traveling this spring, I had a throat so sore I ended up in a
NJ ER at 6 AM on Easter Sunday. And I don’t go to the ER. Ever. I
couldn’t talk, or swallow, and basically was drooling into a towel.
So yeh, Strep can hurt pretty bad. 1000 mg of Motrin and a bottle of
throat wash barely made a dent in the pain. On another note, my heart
goes out to this young man and his family.
@brian25: Utah’s different though. You do have to be certified – more so than most other states, follow the link – to be a pharmacy technician. And I’m aware of absolutely no state, city, locality, etc. that will allow a pharmacy tech to dispense drugs completely by his or herself without first being checked by a pharmacist. This is a Walmart… say what you will about them, but they’re not stupid enough to not have their own rules and regulations, even if Utah didn’t, to cover their asses in this regard.
Why on earth would a doctor prescribe a schedule 2 controlled substance for strep throat? Yes, Vicodin syrup -no to Tussionex unless you have a terrible cough, and I can think of no reason at all to prescribe this drug.
There is no excuse for a screw up of this magnitude, but don’t put the blame on the tech. He or she did not compound it. This was dispensed by a licensed pharmacist who was careless and did not notice that it should have been diluted. That is what the final check is there for. I am amazed that a retail pharmacy would have this in the first place. I can only find stuff like this at outpatient hospital pharmacies and compounding shops.
I worked at a Wal-Mart pharmacy for 9 months but it was so painful working there I quit. We were always understaffed because they cut the tech hours. However, we had 2 pharmacists on duty at all times. Both of them checked each prescription to ensure accuracy.
This is so sad and I feel terrible for the family and the guy.
@blzbob: “In this case the mistake is minor.” Try telling that to the family. There are some professions where there should be zero tolerance for mistakes. Do you want the aircraft mechanic to make “minor mistakes” on the next flight you take? Do you want your heart surgeon to make a “minor mistake” during your bypass surgery?
@tnycatgirl: I’m a pharm tech, and let me tell you, most people don’t want “personal care”. The only thing people care about is speed. They want their meds and they want out.
I’m in the suburbs of DC and we fill over 250 prescriptions on a “slow” day. With only 1 pharmacists and at most 4 techs or associates (associates do all the techs do here but enter prescriptions) it gets very hectic. You have customers yelling at you to hurry up and get angry when you tell them to wait. Not only that but we have to deal with phone calls to and from doctors, patients, insurance companies, and sometimes the manufacturer/distributor of the drug.
There is always a line and sometimes the line is filled with crazies who are just looking for an argument and cuss at you and the pharmacist. You even have those people who don’t want to pay and will throw stuff at you.
I would assume at any store nothing leaves the pharmacy until the pharmacists checks things over.
What I’ve noticed is the best customers are the ones who work in the medical field themselves. Not saying the mistake is right but they do happen. Even people who are as trained as a pharmacist.
And where do all you techs make so much?!?!?!
- undergrad bio student who wants to get into pharmacy school someday
@rynnassif: Like I said it varies State to State.. in Florida it all has to be checked by a Pharmacist. But they are very busy and the system only works right when it is checked at all levels… to include experienced tech’s and pharmacists. If your tech’s aren’t trained (which they very well could be) then they are more prone to mistakes.
@Snullbug: I think you missed the rest of my comment where I mention that the consequences are not minor. The mistake was a simple misreading. We don’t know why it was misread. There are any number of reasons. We’ve all misread something. The mistake is minor, which means the mistake can easily be addressed and fixed. The consequences of that mistake are dire. That family is dealing with something that I hope no other family will ever go though. Walmart is fully responsible as is the pharmacist. Right now, I’m willing to bet that pharmacist is wondering if he or she is going to keep his or her license.
@some_stupid_nut: I work in Washington State. I currently make more than $17 and I am not PTCB certified yet. Once I get that, I get another buck raise. I am also working on creating a team lead position so I can be the Senior Pharmacy Technician which comes with an additional $3. When all is said and done, within the next year I should be making just about $23/hr including my anticipated annual raise. Note that we have a high cost of living though.
Walphar gave me some guy’s heavy-duty blood pressure medicine instead of the antidote my DR prescribed me for anaphylactic shock in March 2004. Both our names started with “W”, so they swapped the bottles when they put them in the pharmacy paper sacks. The name on the sack was correct, but I had his meds and I guess he got mine. I slept for hours longer than I normally sleep after taking his meds, and I guess I’m lucky I woke up! The next time I was supposed to take the medicine, I actually read the label, and realized it was some other name on the bottle. I took it back to Walmart, and they said they were sorry, that they’re supposed to check the prescription (3) times to prevent mix-ups, but somehow they were switched anyway. The head pharmacist gave me a $5.00 gift card with her apology. They are lucky I was gracious about it, because I could have sued them for that. If I hadn’t woken up, or suffered any lasting effects, or death, I’m sure my husband would have sued them. But I was ok, just felt tired for a couple of days, so I blew it off. I’ve been a customer of theirs for over 20 years, and personally know the pharmacists who work there. I know we’re all human and make mistakes, so I was willing to forgive and understand. I don’t blame this young man’s family if they sue. They nearly lost him, and he may suffer permanent affects because of their mistake.
As a pharmacy technician at a Wal Mart store, I must say that this is completely unacceptable and the only one to be blamed is the pharmacist who visually verified the medication Sometimes we don’t mix suspensions until the customer picks it up so when they yell at us about they’re insurance not covering it and throw it at us, it won’t have to be wasted and thrown away. However, this medication that Jessie took was a CII and it is illegal for technicians to dispense CII perscriptions soooo blaming technicians and calling them stupid really makes a lot of sense.. Oh wait, it doesn’t. Also, just because this was at a Wal Mart doesn’t mean they gave Billy Joe who usually works in the garden center a promotion to pharmacist status. They have to go to college for an average of 5 years and be licensed by the State Board of Pharmacy. Maybe if you people wouldn’t expect us to wave our magic wand and automatically, input, four point, screw around with your 500 insurance plans, fill, and visually verify your perscription; all the while having the phones ring off the hook while taking care of other customers (yes! you aren’t the only one we’re filling for!)–there would be less rushing and therefor less error. HOWEVER, errors are still NOT acceptable and you would think thatwith all the laws and precautions behind dispensing a CII, the pharmacist would have been more careful. Wal Mart better pay up!
I’m stationed at Fort Campbell KY, and 2 weeks ago wal-mart filled a med for my child that was supose to be only 2mgs 2times a day. I ended up getting 20mgs 2 times a day for a 7 year old. that he ended up in the hospital were he is still at…
My thoughts go out to jessie,
from sad mom