$1,050,000 pharmacy mistake

[Marty]

On Jan. 21,2006, plaintiff, an active 80-year old retired officer, had a routine prescription for 2 mg Coumadin refilled at DeWitt Army Hospital Fort Belvoir pharmacy, which incorrectly filled the prescription with 5 mg. tablets.
Plaintiff took the higher dosage for ten days and noticed bloody nose and bruising.He was admitted to Virginia Hospital Center where he was found to have INR that was too high to count, with a PT greater than 100. He was given medication to reverse the hyperanticoagulation, but developed paralysis both legs.
A CT scan showed spinal cord compression from T-2 to T-9 from a spinal hematoma. Plaintiff was left with paraplegia as well as bowel and bladder incontinence.
Settlement $1,050,000 approved by Department of Justice Jan. 2008.

Well what do you think? Was the plaintiff responsible in any way to inspect his tablets more closely? On my generic warfarin its darn hard to see the little 5. Alice, my wife, and a RN also on generic warfarin says she checks her tablet three times every time she takes one. A more detailed review of the proceedings show that this point was never brought up. I'm not sure why. Can our lawyers help here?

 

[geebee]

We live in a world where personal responsibility is being discarded. It's always someone elses fault. When someone wins money for getting burned with hot coffee from McDonalds, there is no settlement that could cause me to be surprised.

Yes, the patient should be responsible for checking his meds but the pharmacist should have filled it properly. Both had responsibilities, IMHO, but then the patient is paralyzed so, based on the state of our society, someone has to pay.

 

[Nancy]

Who has to carry the liability insurance? That is the person who has the responsibility under the law, I would think, since that is the person with the most training and knowlege of the subject. And that person is also holding themselves out to be a professional and expert in the field.

When I had my business, even I had to carry a liability insurance policy for errors and omissions.

 

[ALCapshaw2]

Well what do you think? Was the plaintiff responsible in any way to inspect his tablets more closely? On my generic warfarin its darn hard to see the little 5. Alice, my wife, and a RN also on generic warfarin says she checks her tablet three times every time she takes one. A more detailed review of the proceedings show that this point was never brought up. I'm not sure why. Can our lawyers help here?

How did they discover the prescription error?

I found it interesting the there was NO MENTION of the COLOR difference between 2 mg pills and 5 mg pills. EACH dose has a UNIQUE Color... Hmmm... maybe I need to get a new Coumadin Card that shows the colors and doses!

 

[Bina]

I take 2 and 3 mgs. Both are very pale and hard to distinguish in dim lighting and without my eyeglasses.

 

[Marty]

How did they discover the prescription error?

I found it interesting the there was NO MENTION of the COLOR difference between 2 mg pills and 5 mg pills. EACH dose has a UNIQUE Color... Hmmm... maybe I need to get a new Coumadin Card that shows the colors and doses!

With Coumadin the numbers are deeply engraved and hard to miss. I have an old Coumadin dose calendar that shows the 5mg as a light peach and the 2mg as a light brown. My generic (Taro?) 5mg is a light peach and you need a magnifying glass to see the little 5 which sort of looks like an S. I havn't see generic 2mg but if its sort of a light brown with a number almost impossible to see I understand why the defense didn't bring it up. However the printout of the proceedings I saw said the plaintiff took Coumadin. Any how, be careful. Alice checks her pills when she takes the bottle out of the cupboard,again when she takes the pill at the table, and yet again when she puts the bottle back in the cupboard.This is what the old time nurses were taught.

I don't know how they discovered the prescription error. I suspect that when they found his PT over 100 they checked the bottle to see what he was taking and found 5's not 2's.

 

[Bina]

Coumadin: 2mg is pale mauve, 3mg is pale tan, 5mg is peach.
Can't they make them red, blue, green, yellow, pink and brown like smarties!!

 

[LUVMyBirman]

So unfortunate.

I do feel we need to monitor what is prescribed/filled. In this case the patient was older. What if his eye site was poor? Maybe he lives alone?

Have been given the opposite of what I refilled. Wanted 1's. Given 6's. If I were older or vulnerable and assumed I was getting the 1's and took the 6's. Could have done some big damage. Bottom line. It's up to the pharmacist to make good on what is ordered!

 

[3rdtimesacharm]

HE's 80 YEARS OLD PEOPLE!

HE's 80 YEARS OLD PEOPLE!

I don't really want to generalize and say that older people have site problems...but on the other hand "generally" they do! I can just imagine my 80+ year old grandpa doing the same thing. Taking his prescription from his trusted pharmacy and not realizing it was the wrong dose. Even if it was a noteably different color (which it is) he could have dismissed it as a change from the company that makes it. I think the pharmacist is fully responsible for the mix up! Of all the things to screw up, Coumadin is NOT the one to mess with!

How sad that this man now has to deal with being a parapallegic for his remaining years! No amount of money can make up for that.

PS: I deal with military pharmacies all the time (I'm an Army wife) and they tend to be a little hairy scarey. I constantly check all of my Rx!

 

[hensylee]

I don't know if we have any lawyers left, Marty.

The final responsibility is the pharmacy. Settlement was not enough to cover this grave injury to any patient. that's my 2 cents worth

 

[Mary]

I'm color blind for certain colors, and I wouldn't be able to tell the difference between mauve/peach/tan.
Frankly I'm surprised that he didn't receive more; would anyone change their life to what's he left with for a million dollars?

 

[perrypiratesdad]

This is why we need medical reform in the USA. I agree that the pharmacy was at fault, but I think the judgment amount is excessive. Yes the person is messed up for the rest of their life, but will $1M+ really make things better?

 

[Lisa in Katy]

Ultimately, the pharmacy who filled it wrong is responsible. We mere mortals can't be expected to know the difference. At 80, perhaps his eyesight wasn't great. I have 1, 3, and 6, which are pink, brown, and blue, so very different in color.

It shocks me that his INR was off the charts in such a short period of time. Generally speaking, 5 mg is a low dose. I alternate between 7 and 9 to maintain around 3.5. He must have been extremely sensitive to Coumadin.

 

[KristyW]

.

It shocks me that his INR was off the charts in such a short period of time. Generally speaking, 5 mg is a low dose. I alternate between 7 and 9 to maintain around 3.5. He must have been extremely sensitive to Coumadin.

Lisa,

Since he only takes 2mg but he was given 5mg...figure that his dose was more than doubled. Couple that with the slower metabolism of an 80-year-old, it wouldn't take long for the INR to skyrocket.

As for who's responsible, well the pharmacy for the error. But as consumers/patients we are reminded to make sure we are getting what we pay for. There are notices at my pharmacy to double check that WE (the patient) receive the correct and prescribed medication.

This is something that we all need to take responsibility for no matter what our age.

 

[Mary]

Regarding the amount of the settlement, it's not whether it will make it better. It's a matter of whether it will pay the expected costs for his life expectancy. As a paraplegic, his ongoing medical expenses could very well reach the million dollar mark.

 

[sknydave]

Just a messed up situation all around.

And regarding the McDonald's coffee lawsuit, McD's knew the coffee was being served too hot. There had been hundreds of injuries prior to the elderly woman's. The woman had stated several times that she would not have sued had McD's simply paid her medical bills. She was actually very badly injured. I think she required skin grafts and all.

 

[Marty]

Very good response. Absolutely right on. Check your warfarin refills carefully. Offer to help older relatives and neighbors who are on their own. Thats all we can do.

 

[KristyW]

Oak,

I apologize if my post came off as blaming the patient. I certainly didn't mean that, and I certainly don't know all of the circumstances of what happened in this particular case.

I said first off that the pharmacy/pharmacist is the responsible party.

With that goes the "human" aspect of life and that none of us are infallible, and we all must be aware of possibilites. I've relayed this story before but it bears repeating...My daughter had pheumonia when she was 2 1/2. I took her to the emergency room and went all through what that implies...at the end of our visit, the Dr gave me 2 prescriptions and walked out the door. I looked at them after the door closed and I couldn't read any of it. When the PA came in to release us I asked her what they said and her reply was "The pharmacist will know". I told her, how will I know the pharmicist gave me the right Rx if I don't know what I'm supposed to be getting? I actually had to bully her into getting the Dr. to come in and tell me what the prescriptions were. Another instance, I recently changed Doctors due to an insurance change. I brought in my medications (in their original containers-labels intact). The PA wrote them all down, and at the end of the appointment my Dr. gave me Rx's for refills (had to change pharmacies too). Unfortunately the PA didn't write down that I was taking Toprol XL, she just wrote Toprol (I didn't see that until I was at the pharmacy). She also didn't write down the strength of my Birth control pills. I actually ran out of them before my mail order pharmacy could refill it (and I gave the 3 weeks lead time). As I said, we deal with humans, and in the medical profession they're all under tremendous time constraints. Mistakes are made, and if we don't check, we're the injured party.

In the case of this 80 year old gentleman, it's completely possible that he's going to a trusted pharmacist, or he can't see the markings on the pill, or that there's some colorblindness, we just don't know, but someone should check or ask for his own protection. There are no easy answers, our aging population is at risk for this sort of mistake. They do the best they can, many do not like to ask for help, or there just isn't help around.

I'm very sorry for this gentleman, no amount of money can compensate for paralysis.

 

[Dennis S]

I am probably in a unique position concerning this question. I am a lawyer who has done this type of work. I am also a person who was paralyzed from the chest down for a significant part of my childhood. I was paralyzed by childhood polio, and regained my mobility (nearly completely) over a long period of rehabilitation.

I have read about the occurrence of something called "post polio" syndrome that has been revisiting the paralysis of childhood polio on many adults who fit my profile. I mention this because just the possibility of going back to my paralyzed condition felt like it might destroy me. It is that bad.

A pharmacist who makes a mistake is not a bad person. There are no bad people in this scenario. But, the responsibility for a correct prescription lies primarily on the pharmacist. That is why he has a license. He would be the first to tell you that it is a terrible idea to leave the public responsible for getting their prescriptions correct.

I have no animosity towards the pharmacist. But if I was going to have been on the jury--the defense would have been very wise to have settled for that amount. In my opinion it is about 20% of what I would have required to settle this claim.

 

[TinaK]

Really makes me think....

Really makes me think....

I never thought to question my pharmacist that closely. I figure they are the experts, I dont fault the old man, we rely on our health care professionals to have some type of checks and balances in place to protect us from this very thing. It was a crime, in my opinion.