A Manitoba couple is pushing for more safeguards in how pharmacies supply medication after their daughter overdosed on a pill dispensed at a Shoppers Drug Mart that had 10 times the dosage her doctor had prescribed.
“This isn’t just a ‘my bad scenario,’ this is a bigger situation,” said Kevin Barkley, the girl’s father. “You take 10 times the dosage and you don’t get a lot of variance there to stay alive.”
Barkley’s 10-year-old daughter had a prescription for a two milligram pill she was ordered to take daily.
CBC News has agreed not to share the name of the medication to protect the girl’s medical history. But a number of medical journals say overdosing on this type of medication can lead to drowsiness, hypertension, tachycardia, seizures and other issues.
When a family friend went to pick up the medication at a Shoppers Drug Mart store in Winnipeg’s Dominion Centre earlier this month, she was given a bottle labelled and filled with 20 milligram capsules.
The family friend gave the girl a pill on Aug. 13 while she stayed with them during a trip. Barkley said his daughter was lethargic and “blacked out” most of the day after taking the medication.
The next morning they gave the girl a new pill — but this time she vomited. Her father said the family friend contacted them and sent a picture of the pill to the girl’s mother.
“I just panicked, my heart started racing,” Andrea Thidrickson, the girl’s mother, told CBC News. “The dose was much higher than what it should have been … but I didn’t know how serious it could be.”
She contacted The Manitoba Poison Centre and her daughter’s pediatrician, both of whom urged Thidrickson to take the girl to the hospital as soon as possible.
“That’s when it got pretty scary. All I could think about was, ‘is she going to be OK.’ That’s my baby,” Thidrickson said.
At Winnipeg’s Children’s Hospital located within the Health Sciences Centre, doctors told the family the girl had overdosed and with the medication already in her system for more than 12 hours, the only option was to wait for it to clear, said Barkley.
“It makes me sick to my stomach and a little bit angry too, because it just shouldn’t have happened,” Thidrickson said.
A medical report shared with CBC said the girl had normal vital signs and neurological function but she needed to be monitored in hospital before she was released.
The 10-year-old made a full recovery, but her mother said her daughter was so scared of taking the pill again that she was taken off the medication with her pediatrician’s approval.
The girl’s father said doctors were concerned about her daughter’s heart slowing down after overdosing. But they said the family was lucky because the girl’s body rejected the second pill and had she not thrown it up, she could have been at higher risk of going into a coma and even dying.
“We are just trying to bring awareness so this doesn’t happen to somebody else because it was very apparent how easily it could have changed our lives forever,” Barkley said.
Barkley said his family contacted the pharmacy, Loblaws Ltd. — Shoppers Drug Mart’s parent company — and Manitoba’s College of Pharmacists to report the incident. Initially, only the owner of the Shoppers Drug Mart store returned their calls.
“Right off the bat, it seemed like nobody made a big deal about it. Nobody really cared. We just got blank apologies,” Barkley said.
Then after the couple spoke about their case publicly, Loblaws and the College reached back to them. Both apologized and told them an investigation was ongoing.
A spokesperson for Loblaws Ltd. said in a statement that the company “takes this matter very seriously” and they have conducted a thorough investigation.
The statement also said “corrective measures” at the pharmacy where the medication was dispensed have been implemented so it doesn’t happen again — but it didn’t share specifics.
CBC has reached out to the College of Pharmacists.
Guidelines from the regulatory body say pharmacy managers must ensure changes are developed and implemented to minimize the chance of a medication incident from recurring.
The couple is filing a complaint with the College of Pharmacists and Barkley said they will continue pushing for changes to come out of the review — especially since these kind of mistakes are far from isolated.
Pharmacies in Manitoba reported 1,348 medication incidents between Oct. 1 and March 31, according to latest available data from a national repository.
Just under two thirds of those incidents happened during the prescription preparation and dispensing stages. Of the reported cases, 230 of them were regarding the incorrect dosage or medication frequency.
No deaths were reported, but 96 patients suffered mild harm, six suffered moderate and one severe harm.
Barkley would like to see pharmacies improve their workflow and include new steps to verify an employee enters the right information from the prescription into the system and dispenses the right medication to the patient.
“There were so many avenues where this could have been caught,” he said, including at the time the prescription was read, the bottled filled and the medication handed to the customer.
“It wasn’t and to me, that is just blatant neglect,” Barkley said.
“They should be double-checking to see who this medication is going to … and that dosage should have never been given to a child.”
