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How a Pharmacy Could Have Killed My Baby this Week

Baby girl

Peony tries to get some sleep without coughing

It’s been a long few weeks. First my 3-year-old daughter Petunia came down with RSV and a double ear infection nearly two weeks ago. Then this past week my my 3-month-old daughter Peony came down with RSV and an ear infection, too.

Unfortunately neither of those is the worst part of this story.

The pharmacy that filled the prescription for Peony’s ear infection could very well have killed her.

It was last Wednesday when I brought Peony back to the doctor for the second time in three days because she seemed to be getting worse. That’s when our lovely and loving pediatrician noticed she had an ear infection on top of a respiratory virus. So she called in a prescription to a pharmacy to treat her ear.

After giving Peony her medicine on Friday, which was day 3 of 5 of the medicine, I noticed the bottle was empty. So I called the pharmacy.

“You didn’t give me enough of the medicine,” I told the woman who answered the phone.

“You must have administered it incorrectly,” she said to me.

Clearly she isn’t a mother. “Actually, I definitely did not administer it incorrectly,” I said. “I followed the directions on the bottle exactly.”

She put me on hold for a few minutes. “We’re actually out of that concentration of that medicine,” she said when she returned to the call. “We’ll give you the equivalent and you can come by and pick it up.”

“So you must have given me whatever you had left and failed to tell me that it wasn’t enough when I got it initially, right?” I asked.

“Right,” she said.

But wait. It gets worse.

I brought Peony back to the doctor shortly after I hung up the phone for a scheduled follow-up appointment. The pediatrician noticed a rash on her chest and back.

“You know what?” she said. “I’m worried she’s having an allergic reaction to the antibiotic. Her ear seems to have cleared up, so please don’t give her anymore. But I would call the pharmacy to complain. That’s incredibly inappropriate that they knowingly gave you the wrong amount of medicine and didn’t tell you.”

As I left the doctor’s office I called and asked to speak to the pharmacy manager.

“Actually,” he said. “We gave you the right amount. We just wrote the wrong dosage on the bottle. She was supposed to take 1.5 milliliters, but we wrote 1.5 teaspoons. But don’t worry. It’s not quite an overdose.”

I paused. “Not quite an overdose? She’s a 3-month-old baby!”

“Your particular doctor always under-prescribes anyway. 1.5 milliliters isn’t much more than 1.5 teaspoons. Mistakes happen,” he said coolly. (“I under-prescribe?” the pediatrician fumed when I relayed the information to her. “How dare he say that? I gave her the exact and utterly appropriate amount!”)

“It’s more than 5 milliliters more than what was prescribed, and she was only supposed to take 1.5 milliliters!” I cried. “She’s only 14 pounds! She’s only 3-months-old! How can you say that doesn’t make a difference?”

When I called the pediatrician, who besides being loving and lovely is also always calm and even, got very silent, but her rage was evident. “They wrote on the bottle to give her 1.5 teaspoons, not milliliters?”

“Yes,” I said.

And then she got very quiet. “If this had been any medication other than an antibiotic, she would be dead right now.”

PLEASE let this be a cautionary tale for all parents: When your doctor calls in a prescription, please also write down exactly what has been prescribed and compare it to the bottle. There’s probably only a one in, like, a million chances that it’ll be wrong, but my baby could have been that one in a million.

And it only takes one.

Postscript: Another pharmacy manager and the pharmacy owner have since been in touch to apologize profusely and let us know they are horrified by what transpired and are investigating the mistake internally. We are filing a complaint with our state’s Department of Regulatory Agencies to ensure the pharmacy is held accountable for their actions, and in the hope that this kind of mistake can never happen again at this pharmacy.

Image: Meredith Carroll

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