Monday Pharmaceutical Mystery: June 1

DB is a 13 year old boy. His parents come into the pharmacy to pick up his prescription for methylphenidate (Ritalin, Novartis). The insurance has requested a change from name brand to generic. You ask the parents if it would be okay to use the generic product, or would they like to pay full price for the name brand. The insurance will no longer pay the name brand so the parents choose to switch to the generic product.

Three weeks later you get call from your legal team informing you that the child has died as a result. What happened?

Mystery: How did switching from name brand to generic cause this child’s death?

Solution: When the switch was made, the product name on the label changed from Ritalin to Methylphenidate. In the CII vault, methadone was in close proximity to the methylphenidate and that product was inadvertently used to fill the order.

The family did not detect the error because the appearance of the pills was unfamiliar to them. Methadone was accidentally given to the child instead of the methylphenidate.

This case is based on a true story, and the dispensing error was just 1 of the mistakes that lead to the death. There were also errors that occurred in the emergency department, twice when the patient was misdiagnosed.

REFERENCE

Discovery Life. Dr. G: Medical Examiner. Deadly Remedies. https://www.youtube.com/watch?v=_UFdhcCMzu8 Accessed May 31, 2020