Mislabeled Medication From Target Prescribes Five Times The Dose For Child

Just because a medication comes from the pharmacist, that doesn’t mean you shouldn’t double check the label carefully, as one mother recently discovered. After she read over the dosage instructions on a medication from Target for her sick 18-month-old, she realized it was way too high.

CBS2 in Chicago reports on the mistake, which instructed one mother to administer 3.5 teaspons of medicine, instead of only 3.5 milliliters. A teaspoon is equal to almost five milliliters.

“I almost didn’t even think twice,” she said. “The only reason I questioned this one was because I needed to get another syringe to administer this one dose.”

Upon calling the pharmacy and hearing the right dose, the mom was surprised that there wasn’t more of a reaction from the pharmacist.

“It was just, ‘Oh, sorry about that.’ Like, I don’t think she had really thought about the severity of how big of the mistake was that she had made,” she told the station. She also confirmed the dosage with her pediatrician.

The Illinois Poison Center said an overdose could have made the child very ill — causing upset stomach, nasuea or diarrhea.

Target officials said, “we take these situations very seriously and thoroughly review any incident involving errors … to ensure we take appropriate action.”

Mislabeled Prescription Almost Resulted In Overdose For Elgin Child [CBS2]

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  1. sirwired says:

    If this dose is higher than what is ever administered to a child of that age, the Pharmacist should receive a formal reprimand. One of the jobs of the pharmacist is to ensure that dosages (or medications) that simply make little sense are at least verified with the prescription and/or prescribing physician before being handed over to the customer.

    • ChuckECheese says:

      Personally, if the pharmacist or other employee simply apologized sincerely that might be enough for me – I do realize mistakes happen. But the attitude too frequently is for medical professionals to refuse to admit to mistakes and to treat people who call them out on errors harshly. This is why people sue, because they don’t feel like they’re being respected, not because they necessarily looking for a payout.

    • Phexerian says:

      Lol. Yes, all pharmacists should be punished for making an error; even when the error was caught and caused no harm! Sorry, but that isn’t reality. Pharmacists make mistakes filling scripts just about every day. Mistakes happen. It isn’t something we like and of course any overdose has the potential to cause harm, but if no harm was caused, punishing every pharmacist for every mistake is just going to make it more time consuming and expensive and difficult to get prescriptions filled. Remember, pharmacists regulate themselves and we don’t like to see our profession look bad and don’t like to see the public we serve harmed, but we aren’t going to ruin our profession either. It’s rough enough as it is right now for retail pharmacists.

      -A Pharmacist

      • pika2000 says:

        Sorry, but pharmacists are not human, thus they are not allowed to make mistakes. Just look at how big retail chain pharmacies treat their pharmacists. Long shifts, no help, no break, no bathroom break, no lunch, etc. It’s clear that these companies don’t consider pharmacists as humans. Maybe you as a pharmacist should stand up for your profession so people will actually start to respect you. Look at naturopaths and registered nurses. Depending on what state, those professions can even prescribe medications, while pharmacists cannot even change anything on a prescription without talking to a prescriber.

  2. GuyGuidoEyesSteveDave‚Ñ¢ says:

    THANK YOU GADGET. We finally have a parent who cares about her/their child enough to take 1 minute to read the label before giving it to their child. But I’m sure people in the comments will blast her for being a helicopter parent, or a tiger mom, just because she cares for her child’s safety.

    • taaurrus says:

      I caught a mistake like this too cuz I read the label ~ my comment/story is below. You should ALWAYS read your prescription label whether it’s your child’s prescription or your own. Actually ~ you should check EVERY prescription label prescribed to anybody your responsible for. My VETERINARIAN’s assistant did the exact same thing to my cat a few months ago as the pharmacy did to my daughter when she was a baby. Correct dosage on my cat’s chart? 0.1 ml (zero point one) ~ dosage the assistant typed? 1.0 (one point zero). The ONLY reason I caught this was because I could see my cat’s chart & I saw what the doctor had wrote & that it didn’t match what was typed on the label. And you guessed it ~ it did NOT seem like a big deal to them when I pointed it out. It was just like “oh, oops ~ I’ll print out another label. Here ya go!”. What’s a helicopter mom? Cuz if this mom sounds like one to some people then I must be one too!

    • CreekDog says:

      How is she supposed to know, as a parent, when a dose is incorrect?

    • Hoss says:

      The label was wrong — but the dose didn’t fit in the syringe. If it fit and the kid died — then you could chime in with parent responsibility Hold on smarty

    • CreekDog says:

      you were quick to blame the parents in the other case, but there is no blame for Target in this post. since you never take the side of the consumer and usually simply insult them, including “not feeling a bit sorry” for the children who got the cancer medications in your comment on the CVS story, it’s fair to say you’re biased, also fair to say that you’ll insult parents and children but won’t do the same to a company.

  3. Rob says:

    She should also report the incident to her state’s pharmacy board.

    They take these things setriously too and can pull the pharmacists license if there is a pattern of mistakes made.

  4. DoubleShortMILF says:

    Too many dumbasses are getting pharmacist jobs.

    • Hi_Hello says:

      bingo.

      I don’t understand why they can’t replace them when vending machines…

      • DoubleShortMILF says:

        Seriously. Doctors just send the scrips in to the pharmacy – you’re telling me that most of these scrips can’t be automated?

        • Phexerian says:

          sure they can be automated. but the automation won’t decide if the medication you are getting is safe for your pregnant wife to which the automated machine has no clue if she is pregnant. The machine also can’t bill your insurance automatically so you will have to pay cash for all prescriptions. The machine also can’t decide which drug interactions are ok to not worry about and which ones are ok to worry about. Also, automation is also only as good as the input of the automation. If you have incompetent people setting up the machines, you are only going to hurt even more people most likely.

          I don’t know if you realize it, but pharmacists have PharmDs. It’s a medical degree that is a doctorate. Its along the same lines of MDs. They focus on diagnosis and treatments, we focus on drugs and treatments. You think PharmDs can be replaced? Try and get into pharmacy school and see how many people you have to beat out to get accepted. When I applied, it was over 2900 people for 198 slots and the average GPA (3.6) was higher than those accepted into the medical school here (3.5). It is even more competitive now. A machine can’t function as a pharmacist.

          Guess what? They have programs now that can do diagnosing for MDs. You input the data and it tells you what the most likely diagnosis is. But it takes a MD to figure out what to prescribe for what the actual diagnosis is and what is prescribed is actually safe. Do you think all MDs should now be replaced by computer programs?

          -A Pharmacist.

        • Andreth says:

          I’ve had several doctors send prescriptions in that would not have been appropriate for me. These were caught by pharmacists.

          In one case, it was a migraine medication that was contraindicated in patients with circulatory disorders as it can cause necrosis of tissue. Nevermind the fact that my doctor is aware of my condition and it is noted in multiple place in my record. When I arrived at the pharmacy after my Dr appt they told me that they hadn’t filled the prescription because of this. When I called the Doctor, she said “Oh right! I hope you didn’t take any. I’ll prescribe something else.”

          On the other two occasions it was interactions with other medications I was taking… medications prescribed by the same doctor. I don’t expect them to be perfect, but it would be nice if they read the record enough to know what other meds they had put me on.

          I am glad there’s someone checking these things. Doctors do study medications, but not anywhere near to the extent that your pharmacist does.

      • catastrophegirl chooses not to fly says:
  5. ChuckECheese says:

    A couple days ago in another thread, there was this pharmacist who arrogantly claimed in reply to my post that if a pharmacist made an error – and they never do – they would quickly fess up and make it right. That person was replying to my post about a serious error I had in a script once where the pharmacist refused to admit the mistake until an assistant called her out on it, and I had to file a complaint with the board of pharmacists. In that post, my character and integrity were trashed, because that’s what medical professionals do, is go on the defensive, preferably with character assassination, when somebody complains about medical misconduct. This is also why in my work field, there are laws on the books fining people for refusing entry for inspectors and fines and license suspension for people who slander or retaliate against inspectors who are doing their jobs. That poster was the perfect example of what’s wrong. Many medical professionals are in it for the money and not to heal people. You have to know the difference and stay away from those who don’t hold you in equal esteem to themselves.

    • Guppy06 says:

      Congratulations, you won an internet debate.

      Sorry, there are no medals.

    • Phexerian says:

      1 – Actually I was calling bullshit on your story. It didn’t quite add up. You claimed a pharmacist purposefully filled your prescription incorrectly because he didn’t have it in stock. That’s a very very very far fetched claim.

      2- Also, this is the fucking internet, not my pharmacy. If you are a patient, you get different treatment from me.

      3- Apparently I am what’s wrong with the entire medical field based on an internet post? Nice job. You want sunshine out of my ass for your sob story? Then get a script filled at my pharmacy while I am being paid to be a pharmacist. I call bullshit on people on the internet for stories which I think are bullshit. I act and work differently at my job because it is what it is, my job.

      4 – Serious medical error? Let a medical professional decide what is considered a serious medical error. Not a layman, meaning you. If it was your little kid who got a dose of 5.5 ml of Zyrtec when it is supposed to be 5 ml, I bet you would claim it was a “serious medical error” when in fact it is quite small. I don’t know the specifics of your claimed medication error so I can’t say what my opinion is on your situation.

      5 – Arrogant? What’s wrong sweetcheeks? didn’t like me questioning your story?

      6 – Medical professionals trash your integrity? Sorry that’s a pretty big platitude and is quite ignorant. Oh wait didn’t you just call me that in your post?

      7 – Yes apparently all medical professionals go for the character assassination thing when there is a medical error. God forbid we actually investigate it first to make sure what is being claimed is true and accurate. Patient’s must hate it when they get questions from the pharmacist regarding their prescriptions to make sure all parties are on even footing. Once again, another blatant platitude.

      8 – Why is it important to state that in your field, whatever it may be, that people be fined for refusing government inspectors? Unless you actually audit for an insurance company in which case, I have the right to refuse you in my pharmacy (though you could always charge back the scripts. Not a fine.) Someone else called bullshit on your statement in the other post as well, not just me.

      9 – I’m sure there are some professionals that are in it for the money. I might just be one of them though you would never know if I am or not. Flying Spaghetti Monster forbid I have the intelligence to use my brain and heal people and make money at it. You expect more than a few kind words, medical advice, and your prescription filled correctly?

      BTW, since you hate medical professionals so much, why don’t you boycott them? You should never want free medical advice from a pharmacist again since you present such blatant platitudes about medical professionals. Perhaps you should never want surgery from an MD because FSM knows, they might be in it for the money!

      If you want to attack my profession, please note that pharmacists are in the top 3 most professions in the united states, up there with physicians and nurses. I think the rest of the United States disagrees with you.

      • Jules Noctambule says:

        I’m so glad you aren’t my pharmacist.

      • bobloblaw says:

        actually, in my 6 months using riteaid, they messed up my and my husbands prescriptions 3 times. one time, f’ing up a routine monthly a prescription with a hardcore drug – no apologies, just’ my bad’ attitude. i said, “well, some people would consider filing a lawsuit after 3 mistakes like this’ – their response was ; “well, since you didnt actually take it, no harm done”. F’ers. seriously wanted to punch them in the face.

      • incident_man says:

        have a chip on your shoulder, do you?

        Just my $0.02

  6. Kuchen says:

    Some of these mistakes could be avoided if pharmacies only used one set of liquid measurements. Enough of this milliliters vs. teaspoons, it should all be in milliliters, all the time.

    • ChuckECheese says:

      Another issue with liquid medications is that a given medication may have a certain amount of a medication – say 0.5 mg of Ativan, added to a different amount of diluent – say 2 ml. These things get a bit tricky. Such meds usually come with measuring droppers that are labeled with the medication on it, so it won’t be used for other meds, labeled with the dosage in mg (even tho it’s a liquid). If you have such a dropper, don’t use it for any med other than the one that came with it.

      • arualflower says:

        When you add a diluent there will typically be a change in expiration date, limiting the patient to only get maybe a 14 day supply at a time. Also, the insurance will not pay for the extra compounding if the medication is already good to go. The baseline is that people usually just blindly take/give medicine and this parent should be applauded for READING THE DAM LABEL

    • taaurrus says:

      In that case ~ you would have to take out the decimals too.

      • Kuchen says:

        Why would you have to take out decimals? As long as you’re writing things the right way (no trailing zeros after decimal points), it should be fine.

    • Phexerian says:

      I agree as a pharmacist. Some pharmacies, though not all, try to stick to just milliliters when typing in labels. Though not all of them do that. I think it is a very good idea though.

  7. ProfOrganizer says:

    I hope this incident is reported to Illinois’ pharmacy board. Also, for what it’s worth (and with that not-fluoride-but-cancer-med mixup earlier reported in mind), I always advise my clients that when they are prescribed new medications, to check them against on online pill identifier like Drug.com’s Pill Identifier Wizard: http://www.drugs.com/pill_identification.html — you type in the drug name and dosage, and it shows what the form (gel, tablet, capsule) color, shape, scoring (or absence of scoring) and imprint should be. Very often, the only side of a different between two dosages is the number imprinted on the med, so being aware of that number is profoundly important.

    There are similar tools at Rx List: http://www.rxlist.com/pill-identification-tool/article.htm and Web MD: http://www.webmd.com/pill-identification/default.htm — I don’t know of any liquid med identifiers, but would be eager to hear if you know of any.

  8. taaurrus says:

    This happened to me too when my daughter was 6 months old. The pharmacy listed her doses to be 8 ml (eight) when I knew it was suppose to be .8 ml (point eight) ~ that’s like 10 times the correct doses right? The only reason I knew is because it was a refill. If it hadn’t have been ~ I would have given my daughter the doses listed and who knows what could have happened. And just like with this story; this pharmacy didn’t seem to care that much either. A mistake like this could cause a death ~ incompetent people should NOT be allowed to do things like handle people’s medication. Not to say this was a case of incompetence ~ probably more of a case of rushing or just not caring or not double checking or all of the above ~ but there still are WAY TOO MANY incompetent people who DO work at pharmacies and the mistakes they make can have deadly consequences. Which is exactly why Safeway just lost almost $1000 a month from my family cuz when their totally INCOMPETENT pharmacy tech’s messed up our medication for about the 10th time; and the only competent pharmacy tech they had transferred out ~ I transferred all my families medication to a different pharmacy. Stores should really have better training for people who have the power to severely hurt or kill someone because they are costing themselves money ($1000 a month loss just from my family alone) and setting themselves up for lawsuits. As I was checking out last month after informing the pharmacist that I was transferring ALL of my families medication to another pharmacy and also telling him why ~ I overheard the most incompetent pharmacy tech there tell a coworker that he had “transferred from the deli”. ???!!! Seriously? Well, that explains everything. Safeway actually thinks people who work in the deli can just be transferred over to the pharmacy ~ cuz you know, cutting meat is every bit as dangerous to the customers as handing out the wrong doses/wrong prescription to a customer. Maybe Safeway should get some competent people at the CORPORATE office as well! I’m glad to know this mom was paying attention ~ same as I was. Our kids were unharmed because we did. But what about the next mom who doesn’t read the label/trust the pharmacist did his job right and/or simply doesn’t realize the dose is wrong? What about that child? How many people have to get hurt before stores stop putting every tom, dick & harry behind the pharmacy counter??

    • Phexerian says:

      I very much agree with you as a pharmacist about putting random people in the pharmacy. Pharmacists don’t like it as we also have trust issues with employees being around so many narcotics and other abused substances. But it also takes 6 months of working full time as a technician to be fluent in the retail pharmacy world. Unfortunately, companies don’t want to pay technicians enough money and they don’t want to pay out enough hours in the budget for pharmacies to safely and accurately dispense prescriptions. This goes for EVERY major chain pharmacy. Unfortunately, its hard to find good pharmacy technicians and training one is even harder. Many people don’t stay because of the high stress environment to which we have to start the process all over again.

  9. lovemypets00 - You'll need to forgive me, my social filter has cracked. says:

    I know my doctor probably rolls his eyes when I ask him to spell the name of a drug (if I can’t) and tell me the exact dosage, but I write this down at my visit, and I double check when I get the prescription at the pharmacy. My mom taught me that – she’s an RN and dispensed medications, and advised me to always double check.

    • Cor Aquilonis says:

      Good idea. I will copy it.

    • Kuchen says:

      She taught you well. I’m not sure if she does this for everyone or just because she knows I’m a nurse, by my daughter’s pediatrician will show me the calculation she does to get the dose of any medication she prescribes.

    • frugalmom says:

      That’s a great idea. My rheumatologist has the worst handwriting my pharmacist has ever seen. She couldn’t even read my name, much less the name of the medication. I’d written it down, otherwise we would have had to call him.

      • pika2000 says:

        Yet according to most laws, if there’s a mistake in regards to the legibility of the prescription, it’s the pharmacist’s fault, not the doctor. This shows you who has more influence. Board of medicine >>> board of pharmacy.

  10. Velifer says:

    What’s the appropriate response from the pharmacist?

    “OH MY GAWD! HERE! TAKE THE KEYS TO MY CAR WHILE I WRITE MY BANK ACCOUNT NUMBERS DOWN IN THE LAST DROPS OF MY BLOOOOOOD!”

    • ProfOrganizer says:

      No, it’s, “My goodness, I’m so sorry. That must have been very scary. Tell me how you figured it out.” “Let me tell you the procedures we have in place to prevent such things from happening. Can you stand here while I try to figure out what happened?”

      Then go off and research the doctor’s handwriting, the electronic Rx submission, the pre-set instructions in the computer, the name of which pharmacist or tech who may have caused the problem, etc. Return with an explanation or a further apology and promise to continue researching it. Explain what you can. Apologize for the inconvenience and worry. Confer with your store manager and/or pharmacy manager and have them contact the store attorney or corporate office regarding legal issues as well as providing the customer with a gift card. Follow up with a letter to the customer, reiterating the apology and the policies and explaining what will be done differently to prevent the problem for being able to occur in the future. Then actually change the policies and prevent the problem. That’s how one is SUPPOSED to handle apologizing to a customer in such a situation.

    • MMD says:

      How about an acknowledgement that the mistake could have had serious consequences?

    • rookie says:

      i get the distinct impression you don’t give a crap…
      take these seventy pills and call me in the morning…

  11. alliebeth says:

    This is why I like my Kroger’s system of checks…we get your script, the tech (or me, intern) types it into the computer and scans the image. Most pharmacies at this point go ahead and let it be dispensed, then the pharmacist checks it AFTER the fact. At Kroger, after typing it goes into “pre-verification” where the pharmacist JUST checks the script. Then it gets approved, dispensed and then checked AGAIN for the correct pills, etc. They say this lets the pharmacist focus on the correct script only at first rather than the pills and interactions, etc. My pharmacist catches a lot of errors that the techs type in this way. Even certified techs can be stupid.

  12. frankrizzo:You're locked up in here with me. says:

    I got a call from my pharmacist a couple of months ago. She asked me to check my prescription to see if I got 10 tablets too many. I did.

    The medicine??? Oxycontin. It took a physical inventory to catch this mistake. To compound matters, I was asked if I just wanted to “hold on” to those until next month. I asked her if she needed these back to correct her inventory. She said no but called back 10 minutes later.

    I took them back to the pharmacy. Scared the crap out of her.

    • alliebeth says:

      Oooh…that’s a HUGE no no for CIIs….Every pill must be accounted for in the inventory after EVERY Rx goes out, each day at least. Even broken pills have to be recorded. That is so strange that that would happen though; controls have to be double counted when dispensed, and usually the pharmacist counts again when verifying, so triple count. That’s a BIG oops.

      • frankrizzo:You're locked up in here with me. says:

        It’s a small pharmacy. Walgreens across the street made numerous mistakes. They don’t keep enough in stock so I get a partial and have to go back. When I went back, they gave me the whole prescription instead of the remainder.

        • GuyGuidoEyesSteveDave‚Ñ¢ says:

          WHOA WHOA WHOA. They give you a partial Schedule II script? My pharmacies never do that.

  13. shthar says:

    Ok, I’ll ask what everyone is thinking.

    How fat is this kid?

  14. NCB says:

    First of all you need to ask the doc what the medicine is and what the dosage is…and look at your bottles once the tech hands them over. The name and a description of the drug is also on the label (at CVS at least)

    In NC you are asked if you want to talk to the pharmacist every time you pick up a prescription and have to sign a ledger either way. It’s a good safeguard especially if the medication is new.

  15. Theoncomingstorm says:

    I’d have caught the mistake very quickly because, well, I read the prescriptions before I hand them over to the Pharmacist.

  16. gnordy says:

    Interesting. We recently had a prescription filled from Target which told us to give the medicine with meals, which we assumed meant with all 3 meals. When the medicine began to run out several days early, my wife was concerned and learned that we were only supposed to give the medicine twice a day. No big deal, but my son was extra cranky for a few days and that is probably part of the reason.

  17. pika2000 says:

    Well, this is what you get for demanding cheap drugs. With the race to the bottom, big chain pharmacies are killing smaller independent pharmacies. At the same time, since they are selling drugs at low prices, these companies still want good profits, and to do that, they will cut the pharmacy labor. Imagine an ER with just one doctor on duty (no receptionist, no nurse). That’s pretty much what’s going on in most pharmacies today, just a single pharmacist working the whole day without breaks/lunches, standing the whole day. Now do you think a person’s performance is the same at the beginning of the shift and at the end of a 12 hour shift?

    The irony is, these pharmacists are actually asking for it. I mean pharmacists as a profession are a bunch of pacifists. They cannot stand up for themselves, yet they are liable for things like these. I have yet seen any pharmacists speaking up openly about the abuse done by chain pharmacies, how they cheapen the profession and service. They all just bend over despite being liable if they made mistakes. Funny huh.