Re: Medication Errors! Could this have been you?

[Guest guest]

to be honest, when we were going over the drugs we

needed to have, for overdoeses ect., me, the pharmacy

operations co-ordinator, and the pharmacy director had

no idea why the two products had different drug

numbers, and are kept next to each other. I'll have

to look tommarrow and see if we still have both

products or if we got rid of one. all three of us

were looking at it as though it was the SAME product

but by different manufacturers.

so yes this could have been us.

--- Jeanetta Mastron CPhT BS Chemistry

<rxjm2002@...> wrote:

Dear All,

>

> Could this have been you? I was not knowlegeable of

> either of these

> two compounds, sadly to say it could have been me.

> So IF I were in the

> shoes of the tech who dispensed or ever again I

> would have/will

> checked the indications for all drugs that I am not

> familiar with. But

> hindsight is a great teacher and does not save this

> life, hopefully

> future lives. It does not matter that the RPh has

> the LAST check, I,

> the pharm tech, am part of the 'system' in place to

> dispense

> correctly. IF I get the wrong drug, it is possible

> the pharmacist will

> not catch the mistake,in fact I become the first

> part of the

> medication error. IF the pharmacist had dispensed

> the drug by

> his/herself it is possible that he/she would not

> have made the

> mistake. Who knows? Or is it possible that lead

> poisoning is not that

> common, that the drugs have near sound alikes and

> the drugs are not

> that common and that any pharmacist could have

> easily made this error

> by his/her self or with a tech? You be the judge!

> Could this have been

> you? If so WHAT would you be feeling and 'needing'

> right now?

>

> " Toddler's death prompts public message

> Rolling billboard sent out by grieving parents

>

> By LAURA B. MARTINEZ

> The Brownsville Herald

>

> September 2, 2006 - As the rolling billboard

> remained momentarily idle

> on East Van Buren Street Friday afternoon, motorists

> slowed down to

> read the message next to the photo of a smiling

> pigtailed toddler

> cuddling a puppy.

>

> " Cardinal Health Pharmacy killed this child by

> giving her the wrong

> medicine, " the billboard reads.

>

> The photograph is of 2-year-old Alyssa

> of Harlingen

> who attorneys claim died at the negligence of

> Cardinal Health 109 Inc.

> and two of its employees when she was given the

> wrong medicine for

> toxic lead poisoning.

>

> Alyssa was admitted to Valley

> Baptist Medical

> Center-Harlingen in 2005 for treatment of toxic lead

> poisoning and was

> prescribed edetate calcium disodium. She instead was

> given edetate

> disodium, which caused her to suffocate, according

> to a personal

> injury and breach of contract lawsuit filed on the

> behalf of the

> toddler's parents, Alcala and

> .

>

> " They (her parents) were devastated by this, " said

> Austin attorney

> Marc G. Rosenthal who is representing the family.

> " This is something

> that should not have happened. It's inexcusable. "

>

> Alcala declined comment, referring questions to her

> attorney.

>

> Edetate calcium disodium is used to treat lead

> poisoning. Edetate

> disodium is used to treat patients with an abundance

> of calcium in

> their blood or for individuals with irregular

> heartbeats.

>

> Rosenthal stressed that Valley Baptist Medical

> Center is not a party

> to the lawsuit.

> " The hospital has no blame in this at all, "

> Rosenthal said. " They have

> no fault in this at all. "

>

> The toddler's death occurred in March 2005 and a

> $1.5 million

> settlement had been in the works between the family

> and Cardinal

> Health 109 Inc. since around March of this year.

> Talks stalled when

> Cardinal Health 109 Inc. insisted the pharmacist and

> pharmacy

> technician not be sued individually, Rosenthal said.

>

> Cardinal Health spokesman Jim Mazzola of Dublin,

> Ohio, said it was

> inappropriate to comment on the case but said the

> pharmacy has

> continuously expressed its sympathy to the

> family.

>

> " We really express our sympathy to the family. ...

> This is a tragedy, "

> Mazzola said.

>

> The case is pending in court.

>

> The girl's parents hope to prevent other families

> from experiencing

> their heartache and view the billboard as a public

> awareness campaign.

>

> The family had wanted to erect stationary billboards

> along roadways in

> Cameron County, but a temporary restraining order

> was issued by

> Cameron County Court-at-Law Janet Leal prohibiting

> stationary

> billboards from being installed or parked near

> Expressway 77/83 or

> Business 77.

>

> Leal also ordered that billboards not be set up

> within 3 miles of

> Dolly Vinsant Hospital in San Benito, Harlingen

> Medical Center and

> Valley Baptist Medical Center in Harlingen and

> Valley Baptist Medical

> Center and Valley Regional Medical Center in

> Brownsville.

>

> Attorneys for Cardinal Health 109 Inc. filed a

> request for a temporary

> restraining order against the billboard, stating it

> could prejudice a

> jury and cause " irreparable injury " to Cardinal

> Health 109 Inc. and

> its employees.

>

> The order made no mention of a rolling board.

> Moebill Ad out of New

> York was hired to provide the roving ad, which has

> been making its way

> throughout Cameron County.

>

> Rushing of Houston has been hauling the

> billboard and said it

> is turning heads.

>

> " People are constantly looking, " he said. " People

> are stopping and

> actually hitting their brakes, stopping and looking

> at it. I'm at

> stoplights, and it seems like all the focus is on

> this. Trust me, it's

> attracted a whole bunch of attention. "

>

>

http://www.brownsvilleherald.com/ts_comments.php?id=72496_0_10_0_C

>

>

> I feel terrible about this. I can NOT imagine what

> the pharm tech and

> pharmacist feel right now, only that it is worse.

> My prayers are with

> both the family of the deceased, the pharm tech and

> RPh. May they get

> the counseling, support and help that they all need.

>

> Respectfully,

> Jeanetta Mastron CPhT BS

> Founder/Owner

>

>

>

>

>

>

" If the world were perfect, it wouldn't be. "

- Yogi Berra

ONLY AFTER YOU'VE LOST EVERYTHING ARE YOU FREE TO DO ANYTHING

if you have the time to click on an e-mail link like this one:

http://www.sendmoreinfo.com/ID/2425657 you really can earn some extra cash!

__________________________________________________

[Guest guest]

Dear Karin,

THANK YOU for your complete honesty and timeliness. It is a BRAVE thing to

admit. And I respect you for this.

I DO hope that many of the experienced techs on this site WILL return to

hospital work on Tuesday and CHECK this out!!!

LET others on the job know what this is and where they are kept. Maybe a paper

with red letters of the INDICATION in the area of the one for or the other or

both!

Man am I glad I posted this. Almost didn't! While this site is for the study of

PTCB MAINLY it is also here to serve the tech community as a whole and to

continue education whether it is formal with a line to a CE w/'certificate or

for professional development. I hope all CPhT wannabes, learn from our/your

postings that we are always continuing to learn.

AWESOME Karin! get back to us on this one!

Love and Respect

Jeanetta Mastron CPhT BS Chemistry

Founder/Owner

karin h <hockeykatbird_27@...> wrote: to

be honest, when we were going over the drugs we

needed to have, for overdoeses ect., me, the pharmacy

operations co-ordinator, and the pharmacy director had

no idea why the two products had different drug

numbers, and are kept next to each other. I'll have

to look tommarrow and see if we still have both

products or if we got rid of one. all three of us

were looking at it as though it was the SAME product

but by different manufacturers.

so yes this could have been us.

--- Jeanetta Mastron CPhT BS Chemistry

<rxjm2002@...> wrote:

Dear All,

>

> Could this have been you? I was not knowlegeable of

> either of these

> two compounds, sadly to say it could have been me.

> So IF I were in the

> shoes of the tech who dispensed or ever again I

> would have/will

> checked the indications for all drugs that I am not

> familiar with. But

> hindsight is a great teacher and does not save this

> life, hopefully

> future lives. It does not matter that the RPh has

> the LAST check, I,

> the pharm tech, am part of the 'system' in place to

> dispense

> correctly. IF I get the wrong drug, it is possible

> the pharmacist will

> not catch the mistake,in fact I become the first

> part of the

> medication error. IF the pharmacist had dispensed

> the drug by

> his/herself it is possible that he/she would not

> have made the

> mistake. Who knows? Or is it possible that lead

> poisoning is not that

> common, that the drugs have near sound alikes and

> the drugs are not

> that common and that any pharmacist could have

> easily made this error

> by his/her self or with a tech? You be the judge!

> Could this have been

> you? If so WHAT would you be feeling and 'needing'

> right now?

>

> " Toddler's death prompts public message

> Rolling billboard sent out by grieving parents

>

> By LAURA B. MARTINEZ

> The Brownsville Herald

>

> September 2, 2006 - As the rolling billboard

> remained momentarily idle

> on East Van Buren Street Friday afternoon, motorists

> slowed down to

> read the message next to the photo of a smiling

> pigtailed toddler

> cuddling a puppy.

>

> " Cardinal Health Pharmacy killed this child by

> giving her the wrong

> medicine, " the billboard reads.

>

> The photograph is of 2-year-old Alyssa

> of Harlingen

> who attorneys claim died at the negligence of

> Cardinal Health 109 Inc.

> and two of its employees when she was given the

> wrong medicine for

> toxic lead poisoning.

>

> Alyssa was admitted to Valley

> Baptist Medical

> Center-Harlingen in 2005 for treatment of toxic lead

> poisoning and was

> prescribed edetate calcium disodium. She instead was

> given edetate

> disodium, which caused her to suffocate, according

> to a personal

> injury and breach of contract lawsuit filed on the

> behalf of the

> toddler's parents, Alcala and

> .

>

> " They (her parents) were devastated by this, " said

> Austin attorney

> Marc G. Rosenthal who is representing the family.

> " This is something

> that should not have happened. It's inexcusable. "

>

> Alcala declined comment, referring questions to her

> attorney.

>

> Edetate calcium disodium is used to treat lead

> poisoning. Edetate

> disodium is used to treat patients with an abundance

> of calcium in

> their blood or for individuals with irregular

> heartbeats.

>

> Rosenthal stressed that Valley Baptist Medical

> Center is not a party

> to the lawsuit.

> " The hospital has no blame in this at all, "

> Rosenthal said. " They have

> no fault in this at all. "

>

> The toddler's death occurred in March 2005 and a

> $1.5 million

> settlement had been in the works between the family

> and Cardinal

> Health 109 Inc. since around March of this year.

> Talks stalled when

> Cardinal Health 109 Inc. insisted the pharmacist and

> pharmacy

> technician not be sued individually, Rosenthal said.

>

> Cardinal Health spokesman Jim Mazzola of Dublin,

> Ohio, said it was

> inappropriate to comment on the case but said the

> pharmacy has

> continuously expressed its sympathy to the

> family.

>

> " We really express our sympathy to the family. ...

> This is a tragedy, "

> Mazzola said.

>

> The case is pending in court.

>

> The girl's parents hope to prevent other families

> from experiencing

> their heartache and view the billboard as a public

> awareness campaign.

>

> The family had wanted to erect stationary billboards

> along roadways in

> Cameron County, but a temporary restraining order

> was issued by

> Cameron County Court-at-Law Janet Leal prohibiting

> stationary

> billboards from being installed or parked near

> Expressway 77/83 or

> Business 77.

>

> Leal also ordered that billboards not be set up

> within 3 miles of

> Dolly Vinsant Hospital in San Benito, Harlingen

> Medical Center and

> Valley Baptist Medical Center in Harlingen and

> Valley Baptist Medical

> Center and Valley Regional Medical Center in

> Brownsville.

>

> Attorneys for Cardinal Health 109 Inc. filed a

> request for a temporary

> restraining order against the billboard, stating it

> could prejudice a

> jury and cause " irreparable injury " to Cardinal

> Health 109 Inc. and

> its employees.

>

> The order made no mention of a rolling board.

> Moebill Ad out of New

> York was hired to provide the roving ad, which has

> been making its way

> throughout Cameron County.

>

> Rushing of Houston has been hauling the

> billboard and said it

> is turning heads.

>

> " People are constantly looking, " he said. " People

> are stopping and

> actually hitting their brakes, stopping and looking

> at it. I'm at

> stoplights, and it seems like all the focus is on

> this. Trust me, it's

> attracted a whole bunch of attention. "

>

>

http://www.brownsvilleherald.com/ts_comments.php?id=72496_0_10_0_C

>

>

> I feel terrible about this. I can NOT imagine what

> the pharm tech and

> pharmacist feel right now, only that it is worse.

> My prayers are with

> both the family of the deceased, the pharm tech and

> RPh. May they get

> the counseling, support and help that they all need.

>

> Respectfully,

> Jeanetta Mastron CPhT BS

> Founder/Owner

>

>

>

>

>

>

" If the world were perfect, it wouldn't be. "

- Yogi Berra

ONLY AFTER YOU'VE LOST EVERYTHING ARE YOU FREE TO DO ANYTHING

if you have the time to click on an e-mail link like this one:

http://www.sendmoreinfo.com/ID/2425657 you really can earn some extra cash!

__________________________________________________

[Guest guest]

Dear ,

Thank you for the educational posting.

I dont know if this would have been a drug of choice that I would have went

" with, it has some very not so good looking adverse reactions. " Now this is WHY

the Pharm D goes to 6 yrs of school to help make this decision.

I believe there was or is a short supply of varying drugs used for lead

poisoning in the emergency situation. I doubt very much that they had anything

else on hand, and I am not privy to what else could have been used. However

adjunct therapy is dimercaprol. I found no other lead poisoning antedote in my

2003 F & C.

So they probably had no other choice.

Jeanetta Mastron CPhT BS

Founder/Owner

david scurlock <dvdscurlock@...> wrote:

facts on drug in question:

EDETATE CALCIUM DISODIUM Manufacturer: 3M

WARNINGS: Calcium Disodium Versenate is capable of producing toxic effects

which can be fatal. Lead encephalopathy is relatively rare in adults, but occurs

more often in pediatric patients in whom it may be incipient and thus

overlooked. The mortality rate in pediatric patients has been high. Patients

with lead encephalopathy and cerebral edema may experience a lethal increase in

intracranial pressure following intravenous infusion; the intramuscular route is

preferred for these patients. In cases where the intravenous route is necessary,

avoid rapid infusion. The dosage schedule should be followed and at no time

should the recommended daily dose be exceeded.

DESCRIPTION Calcium Disodium Versenate (edetate calcium disodium injection,

USP) is a sterile, injectable, chelating agent in concentrated solution for

intravenous infusion or intramuscular injection. Each 5 ml ampul contains 1000

mg of edetate calcium disodium (equivalent to 200 mg/ml) in water for injection.

Chemically, this product is called

[[N,N'-1,2-ethanediyl-bis[N-(carboxymethyl)-glycinato]](4-)-N,N',O,O',O N ,O N

']-,disodium,hydrate, (OC-6-21)-Calciate(2-).

Pediatric Use: Since lead poisoning occurs in pediatric populations and

adults but is frequently more severe in pediatric patients, Calcium Disodium

Versenate is used in patients of all ages. The intramuscular route is preferred

by some for young pediatric patients. In cases where the intravenous route is

necessary, avoid rapid infusion. (See WARNINGS ). Urine flow must be monitored

throughout therapy; Calcium Disodium Versenate therapy must be stopped if anuria

or severe oliguria develops. (See General Precautions ). At no time should the

recommended daily dosage be exceeded. (See DOSAGE AND ADMINISTRATION ).

I dont know if this would have been a drug of choice that I would have went

with, it has some very not so good looking adverse reactions.

Body as a Whole: pain at intramuscular injection site, fever, chills,

malaise, fatigue, myalgia, arthralgia.

Cardiovascular: hypotension, cardiac rhythm irregularities.

Renal: acute necrosis of proximal tubules (which may result in fatal

nephrosis), infrequent changes in distal tubules and glomeruli.

Urinary: glycosuria, proteinuria, microscopic hematuria and large

epithelial cells in urinary sediment.

Nervous System: tremors, headache, numbness, tingling.

Gastrointestinal: cheilosis, nausea, vomiting, anorexia, excessive thirst.

Hepatic: mild increases in SGOT and SGPT are common, and return to normal

within 48 hours after cessation of therapy.

Immunogenic: histamine-like reactions (sneezing, nasal congestion,

lacrimation), rash.

Hematopoietic: transient bone marrow depression, anemia.

Metabolic: zinc deficiency, hypercalcemia.

There seems to be a lot of salt in this drug... enough for my hamburger...

[Guest guest]

Jeanetta (and everyone),

Here's a link to some more information on Lead Poisoning and treatment:

http://www.emedicine.com/EMERG/topic293.htm

The medications that can be used are listed near the bottom of the

page. Or you can click on " Medications " in the section that is

immediately below each of the Section Headings.

Della

On 9/4/06, Jeanetta Mastron <rxjm2002@...> wrote:

> Dear ,

>

> Thank you for the educational posting.

>

> I dont know if this would have been a drug of choice that I would have went

> " with, it has some very not so good looking adverse reactions. " Now this is

WHY the Pharm D goes to 6 yrs of school to help make this decision.

> I believe there was or is a short supply of varying drugs used for lead

poisoning in the emergency situation. I doubt very much that they had anything

else on hand, and I am not privy to what else could have been used. However

adjunct therapy is dimercaprol. I found no other lead poisoning antedote in my

2003 F & C.

>

> So they probably had no other choice.

>

> Jeanetta Mastron CPhT BS

> Founder/Owner

[Guest guest]

Who ever started this thread with the story from brownsville, Thanks. We had

just started a chapter on medication errors and I brought this article in

and shared it.

W

TiT

[Guest guest]

In a message dated 9/5/2006 11:04:45 P.M. Central Standard Time,

rxjm2002@... writes:

I would love to hear any input your group had to say about the error.

Respectfully,

Jeanetta Mastron CPhT BS Chem

F/O

Well we did talk about how important it was to check your work 2-3 times and

then have it checked by someone else. But one of the things that some

people just could not get off the topic was just who was to blame for the child

being that sick with lead posioning anyway? The parents. But that is a diferent

topic for a diferent list.

TiT

[Guest guest]

Than you ! I started it, but I almost did not. I am sooooooooooooo

thankful that you agree that discussing med errors is important. The crriulum

taht I teach has full 4 hour lecture on QA/QC and Med errors. Students must

find articles about tech and pharmacy errors. Ultimately we talk about how

every depatrent in interrelated to other departments and the checks and

balances.

Too bad it is not a perfect world. Errors do and always will happen because

we are human. But we can diminish the likelihood by following procedures,

knowing all that we can, continuing our knowledge, increasing our

communication, enhancing communication techniques, double and triple checking

orders, etc etc.

I would love to hear any input your group had to say about the error.

Respectfully,

Jeanetta Mastron CPhT BS Chem

F/O

donpieter@... wrote: Who

ever started this thread with the story from brownsville, Thanks. We had

just started a chapter on medication errors and I brought this article in

and shared it.

W

TiT

[Guest guest]

Yes , that is another sad topic. The parents can blame the tech, rph or

nurse or doctor all they want, but they will ulitmately live withthe 'what ifs'

What if I did not turn my back, what if I did not leave that lead pencil out,

what if I had not hired that baby sitter who has poor judgment, etc etc.

These what ifs area what kill the marriage that is trying to cope with the

loss of the child at the hand of another, whether intentional or not.

Many times it is the parents via their own guilt ,who do not want to sue or

place blame on the medical team in a court of law, because they blame

thermselves in the 'first place'. Then sometimes they get caught up in the

lawyers at there door mat, spouting how they deserve to have bills paid and

start a fund intheir child's name etc etc. Thenthe next thing you know e hear

the whole story.

Sad but oh so true.

No amount of money will bring back this child. IF the people/person who

initiated this med error (pharm employees) who continued the error, acted out

of neglect, failure to follow protcol, or failure to act in a timely manner

thenwe with purpose intent to mame or harm, then one could say that this would

be a 5 million dollar law suit . And then I would say 'go for it'. But this

money has quilty consciouness written all over it.

In 2000 Las Vegas ASHP began " To Err is Human " campaign in which we were for

the first time in medical history given a chance not to blame. The TREND is ot

to blame in 2006 but to learn from the mistakes and to move It provides for

counseling for those who were directly or indirectly responsible. Therefore I

refrain from placing blame as I placed in my email onece before. I happened to

have attended that CE. I tend to believe it is true.

Babies and children are most unpredictable. It is difficult to anticipate

their next move.

Thank you for you input.

Respectfully,

Jeanetta Mastron CPhT

Pharm Tech Educator

Founder/Owner

on.donpieter@... wrote:

In a message dated 9/5/2006 11:04:45 P.M. Central Standard Time,

rxjm2002@... writes:

I would love to hear any input your group had to say about the error.

Respectfully,

Jeanetta Mastron CPhT BS Chem

F/O

Well we did talk about how important it was to check your work 2-3 times and

then have it checked by someone else. But one of the things that some

people just could not get off the topic was just who was to blame for the

child

being that sick with lead posioning anyway? The parents. But that is a

diferent

topic for a diferent list.

TiT

[Guest guest]

GREAT Site Della.

Now I do recall " Calcium EDTA " ... I did not recall the long nomenclature of

this drug's generic name.

Even on this page I found no warning of the similarity in names or sound

alike.

There was one drug that appers to be the DOC of children. I failed to write

it down.

Thank you Della, (resident pharmacist!),

I was surprised that the 'foreign bodies' (other than the older homes chipped

paint crackes, plumbing etc ws not further explored. Abotu 15 yrs agon they

stopped the export of all dishware from Mexico until the lead content of the

paints used to

decorate them was changed. Many a plate was destroyed. Some artists pencils

used to have lead, not usre if they still do.

Thanks again,

Jeanetta

<dhengel@...> wrote:

Jeanetta (and everyone),

Here's a link to some more information on Lead Poisoning and treatment:

http://www.emedicine.com/EMERG/topic293.htm

The medications that can be used are listed near the bottom of the

page. Or you can click on " Medications " in the section that is

immediately below each of the Section Headings.

Della

On 9/4/06, Jeanetta Mastron <rxjm2002@...> wrote:

> Dear ,

>

> Thank you for the educational posting.

>

> I dont know if this would have been a drug of choice that I would have

went

> " with, it has some very not so good looking adverse reactions. " Now this is

WHY the Pharm D goes to 6 yrs of school to help make this decision.

> I believe there was or is a short supply of varying drugs used for lead

poisoning in the emergency situation. I doubt very much that they had anything

else on hand, and I am not privy to what else could have been used. However

adjunct therapy is dimercaprol. I found no other lead poisoning antedote in my

2003 F & C.

>

> So they probably had no other choice.

>

> Jeanetta Mastron CPhT BS

> Founder/Owner