PHOENIX - Representatives for a Valley pharmacy say they’re “sorry” for repeatedly refilling a customer’s medication with ten times the dosage she was prescribed.
According to medical records, the mistake, which continued for nearly a year, caused the patient to suffer from painful chest muscle spasms. She also feared her own death.
THE PROBLEM
Sometimes the striking pain would reoccur up to one hundred times a day, according to Larina Helsom, the Phoenix victim. It was so severe, Helsom said, that she couldn’t breathe or talk. She couldn’t lift her new baby out of her crib.
“When it first happened, I actually thought I was dying,” Helsom explained.
She was having esophageal spasms, and doctors tried multiple solutions to stop them, including at procedure at Scottsdale’s Mayo Clinic.
“I never got used to the pain,” Helsom said. “My whole body would turn red and purple.” “I always thought, this is going to be it. This is going to be the one,” she said, talking about how she prepared for the worst possible scenario.
For months, Helsom had been refilling her prescription at the Walgreens pharmacy near Union Hills Dr. and Cave Creek Rd, but no one noticed the 5mcg dose she was supposed to be taking twice daily had actually been filled with 50mcg tablets, ten times the dosage.
DOCTOR VISIT
“She had several subsequent hospitalizations for the spasms as well as numerous medications to try to control the symptoms,” her healthcare provider wrote in a letter supplied to ABC15.
“When we (the doctor’s office) were notified of the medication error, patient was advised to stop the medication immediately. Patient was placed back on 5 mcg bid dose and has had no further spasms.”
According to Vivika Vergara, a Walgreens Media Relations Specialist, “the prescription dose at issue was within the normal dosing range for this drug. The patient was offered consultation for this new medication but declined.”
Helsom said somebody should've noticed the problem sooner.
“There should be some sort of system to prevent that from happening especially over such a long period of time. Somebody should’ve noticed,” said Helsom
AZ PHARMACY BOARD
The AZ State Pharmacy Board is now investigating Helsom’s complaint to determine whether negligence may have been a factor in the mistake.
“Generally we’re not trying to assign blame,” said Hal Wand, the Executive Director, “We’re trying to make sure it doesn’t happen to someone else.”
Wand said many pharmacies have computer software to help alert pharmacists when a dosage is too high for a patient or if drugs shouldn’t been taken together. However, Arizona pharmacies are not required to use computers or special software, Wand said.
A pharmacist, however, is required to counsel a new patient or a patient with a new prescription or drug strength. Some patients refuse counseling.
“I think pharmacists do provide a service that machines and robots can’t” Wand said, “but if they’re not doing that service…it doesn’t do anybody any good.”
Last year, the pharmacy board received 131 complaints about pharmacists and pharmacies statewide.
To put that into perspective, Wand said more than 30 million prescriptions are filled in Arizona each year.
PHARMACY INSPECTIONS
In addition to investigating complaints, the pharmacy board also conducts inspections at the 1,200 pharmacies around the state. Approximately every 18 months, Wand said, every pharmacy in the state is inspected.
According to Wand, inspectors look for a variety of things during inspections, including records maintenance, inventory, and whether proper counseling is occurring between the pharmacist and a customer. Of the 100 inspections filed with the pharmacy board in March 2011, only 13 pharmacies statewide had violations.
“Our goal is voluntary compliance,” said Wand, who explained pharmacies receive a notification if an inspection reveals they are violating a state statute or could improve the manner in which the pharmacy is run.
DISCIPLINARY ACTION
Walgreens would not reveal whether any employees were disciplined for the mistake affecting Helsom. “We are sorry this occurred and we have apologized to the patient,” said Vergara.
“We have a multi-step prescription filling process with numerous safety checks in each step to reduce the change of human error. We have investigated the matter and will work to prevent this type of incident from happening in the future.”
The ABC15 Investigators obtained the most recent inspection report at the pharmacy where the mistake occurred.
In 2010, it “failed to routinely document patient counseling acceptance or refusal on all new prescriptions and corresponding pharmacist’s I.D.”
At the time, the pharmacy provided this written response to the Arizona State Board of Pharmacy:
Everyone has been disciplined and explained to the risks and importance of taking correct documentation of counseling acceptance or refusal. After each day, the counsel logs will be reviewed for any missed counsels and properly documented.
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