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December 25, 2017

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Tragic Pharmacy Compounding ErrorA simple pharmacy compounding error resulted in a boy’s death after receiving the wrong medication and experiencing severe complications.

The child received the same medication to treat his sleeping disorder for a year and a half before taking medicine with the wrong ingredients and dying in his sleep.

A blood screening after his death revealed that not only was the medication prepared wrongly, but the dose of the incorrect medicine was lethal.

There was no shadow of a doubt that the pharmacy compounding error cost the child his life, begging a discussion over what forms of oversight are needed to prevent this type of incident in the future.

Death Caused by Pharmacy Compounding Error

The medication the child was taking for his sleep disorder needed to be prepared by his pharmacy as an oral suspension.

For a year and a half, his family had been filling their prescriptions at the same place, so what seemed routine ended in tragedy simply because the person preparing the suspension reached for the wrong ingredient.

The prescribed medication was Tryptophan, which is normally delivered as a capsule. In this instance, it needed to be taken as a suspension, which meant the pharmacy needed to use a unique process to prepare the medication.

Instead of receiving Tryptophan, however, the child ingested twenty times the lethal dose of Baclofen.

Both Pills Looked Nearly Identical

Since both ingredients have the same color and texture, it is possible for a pharmacist not to pay close attention to using the wrong ingredient when preparing this type of medicine.

Baclofen also comes in a similar package, which is how it is suspected the pharmacist mistook it for the correct ingredient.

The same manufacturer produces Both medications in question, which packages them in almost identical containers.

One way to prevent a pharmacy compounding error in the future could be for drug manufacturers to label their products more clearly and to design packaging that allows products to stand out.

There was also a missing step in verifying the correct substance before compounding the medication.

Finally, a review determined that had a particular identifier been applied to the packaging requiring scanning an NDC number, it would have been nearly impossible to commit this pharmacy compounding error.

How To Prevent Pharmacy Compounding Errors

The following strategies can help each compounding pharmacy reduce the number of medication errors they commit when filling prescriptions and ensure patients do not receive lethal doses of the wrong medication.

  • Only allow compounding of medication in an area designated specifically for this purpose.
  • Make sure that the policies and procedures that need to be followed are accessible to all pharmacy staff members so that they can review and follow proper protocol.
  • Instruct pharmacists to verify all ingredients are correct before preparing the compound or returning any ingredients to the shelves.
  • Before mixing and compounding, the pharmacist could confirm that the weight of each ingredient is correct.
  • Store and label products to reduce the chance that workers may mistake ingredients for each other. This can be accomplished by keeping them at eye level and in a particular location meant solely for compounding ingredients.
  • Invest in routine training, such as showing videos and working hands-on with pharmacists to review the process of creating compounds.
  • Test employees regularly to ensure they remain sharp and are aware of any recent changes to the protocol. Continued education and testing are imperative when it comes to preventing medication errors.

Compounding medicine into oral suspensions is dangerous because there is no way to verify the process was correctly completed afterward.

Pharmacists can tell by the size and shape of a pill, for example, whether it is the correct dosage and medication.

Once the ingredients enter a suspension, however, no visual distinction can be used to tell the completed product apart from another.

Pharmacists occasionally make mistakes, and it is impossible to catch every pharmacy compounding error. There are ways to reduce the likelihood of these errors, however.

Double or triple-checking one’s work and implementing verification steps throughout the process can help employees notice a pharmacy compounding error during their work and change course to correct it.

Seeking Legal Recourse: Options for Victims of Pharmacy Compounding Errors

Victims may have legal options to seek compensation for their damages in the unfortunate event of being injured by a pharmacy compounding error. Compounding errors can result in serious health consequences, and affected individuals must understand their rights and potential recourse through a pharmacy error lawsuit.

It is crucial for victims affected by pharmacy compounding errors to consult a qualified attorney specializing in medical malpractice or product liability cases. They can guide the specific legal options available and help navigate the complexities of the legal process to ensure the best chance of receiving fair compensation for the damages suffered.


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