The first life I saved was my own kid's

I know you're all just itching to find out what happened on our summer vacation next, but I have to let you know about this one. My youngest just had her 2nd birthday so I brought her in for her well child check. (She's 36.5 inches tall and 30#.) She had a routine blood test to see if she was anemic and bummer -- she is. So while I was off at school, my husband picked up the iron prescription for her. (School is great, btw. Most of the students are in the same boat as me, returning to nursing after getting the kids out of diapers and into school buses.) Instead of writing out what happened, the following is the email I sent to the store's corporate offices. And hopefully, by the time of this posting, I will have printed it out and sent it to the local store directly.

This email is just to let you know of a potentially dangerous medication error that your pharmacy failed to catch and could have been lethal for my child if I had not caught it myself.

Yesterday my husband went in to pick up a prescription for my daughter from the (name of the pharmacy and city) location. It was Ferrous Sulfate drops 75mg/0.6ml. The label read "give 2.4 milliliters by mouth daily." I am an RN. When I got home, I was surprised to see such a large dose being prescribed. I checked on the internet to see what the usual dose is, and also looked at the box the drops came in. For severe anemia, the dose is 4-6 mg/kg daily. My daughter weighs 13.6kg. Even at the maximum dose (81mg), it does not come near the 300mg that had been prescribed. I also verified these numbers in the current Davis's Drug Guide for Nurses 10th edition.

Here is where the ball was dropped.

I called the pharmacist after having checked these numbers on the internet telling her that I thought that the dose was far too high. I was telling her about the situation, that the prescription said that I should give 4 droppers of the iron. The first thing she had commented was that she should have included a larger dropper so I wouldn't have to refill the same dropper 4 times. Then I asked her about the dose. She said that she had questioned that large a dose as well, but told me that in cases of severe anemia, doses that large are appropriate. I told her that I didn't think that was right and she suggested that I call the doctor to verify the dose.

I did speak to the MD today and he said that his computer was supposed to calculate the dose based on my daughter's weight, but unfortunately, it did not. He was very apologetic and said that in fact the computer had prescribed a whopping 5mls which would most certainly have caused her injury. The clinic has just adopted this computer system so I can understand some of the confusion.

Thankfully a very dangerous situation was avoided because of the luck that my daughter's mother is a nurse. But I worry that there are many children out there whose mothers or fathers are not nurses, pharmacists, doctors and the like. I am so thankful that my husband didn't take it upon himself to administer the iron before I got home yesterday.

As allied health professionals, we are the last line of defense for med errors. In hospital and in clinic, it is the RN or LPN who plays this role, but in our communities, it is the Pharmacist. I think that the pharmacist must have reduced the prescription to half of what had been prescribed but still not within a safe range. I think she must not have called my daughter's doctor to verify the dose. I think that asking the parent of the child to call the doctor could be a dangerous and irresponsible action. A lay person might have thought that because the pharmacist had already checked the dose, had even adjusted it, that it was not essential to call the doctor, that the problem had been solved.

Thank-you for your attention to this matter. Perhaps you might want to do an audit of the ferrous sulfate prescriptions received from the (name of my daughter's doctor's) clinic considering how grievous this error could have been. Please contact me with the resolution to this matter.

Tess Haddon, BSN, RN

So anyway, no babies were harmed in this incident and my kid is fine. FYI. If a person receives about 10mg/kg of iron, they will have symptoms of iron overdose, like bloody diarrhea, abdominal cramps, and basically pretty nasty stuff. You would need to bring the child into the emergency room and get an IV medication that binds with the iron so she can pee it out. But that doesn't mean she would be out of the woods after treatment. She could develop scarring on her intestines which might lead to a blocked intestine which would be another life threating event. She could get liver failure which would be a life threating event. The dose as prescribed, was about 20mg/kg.

My brother was a pharmacist before he became a dentist. He said that while pharmacists have some limited prescriptive authority (like changing a brand name med for its generic counterpart), it does not include changing a dose all together, as this pharmacist clearly had. And yes, the doctor is at fault as well because he should have verified that the correct prescription had been ordered. I think I am more apt to forgive him because when it was brought to his attention, he was apologetic and absolutely mortified that it had happened. The pharmacist, however, was not.

I have shined up my chest badge that reads, "SuperMommy," knowing full well that I deserve it, at least for today.

*UPDATE* I received a follow up phone call from the pharmacy a full 6 days after the prescription was filled. The pharmacist had finally contacted the prescribing physician and verified that she should be receiving 0.3mls after all. All the refills at the dangerously high dosage have been cancelled.