May 6, 2009 in City

Mother gives baby wrong drug after pharmacy’s labeling error

By The Spokesman-Review
 
Photos by CHRISTOPHER ANDERSON photo

Courtney Lindberg stands at the front window of her home in Colbert. After a drug labeling mix-up, her daughter Lindsay is healthy and home.
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Lindsay Lindberg had needed special help from the start.

The infant was born in November with a heart defect that left her fatigued and unable to nurse. Her mother, Courtney Lindberg, had been filling a host of prescriptions at a Walgreens pharmacy in north Spokane.

Medication was supposed to be a temporary solution until surgeons could patch the holes in Lindsay’s walnut-size heart that had left her weak since birth.

Instead, because of a labeling mix-up, it could have been fatal. Now the mother is urging other parents to double-check the medicines they bring home from pharmacies for their children. Walgreens has apologized for the incident and says it’s spent a billion dollars to prevent similar problems.

The ordeal began about a month ago, when Lindberg refilled her daughter’s prescriptions before they flew to the University of California San Francisco Medical Center for the baby’s open-heart surgery.

For much of that day Lindsay struggled. She squirmed and panted, sweated and refused to eat. Lindberg recalls a long day balancing a fussy baby and travel bags.

After she called her husband, Mick Lindberg, to say they had arrived safely, she gave another dose of medicine to Lindsay. This time the baby spit up. Courtney puzzled over the clear color of the liquid. Until then that particular medicine had been yellow.

Lindberg grabbed the bottle and read the label. Then she looked more closely: The label was affixed to a bottle containing the wrong medicine.

“It floored me,” she said. “Walgreens gave me the wrong medicine, and I had been giving it to my baby all day.”

Walgreens says the case is a rare error, and the baby’s Spokane cardiologist said no permanent harm was done – although it could have been if Lindberg hadn’t caught on so quickly.

Lindberg said she isn’t looking for money and isn’t even interested in an apology. She wants her story told as a cautionary tale.

“What I want is for them to make sure this doesn’t happen again,” she said.

“I know that no one did this on purpose,” she added. “But it’s scary, and I would hope that everyone double-checks their prescriptions.”

The nation’s largest drugstore chain, with 6,736 stores across the country, has apologized and said it’s investigating the case.

“This happens far less than 1 percent of the time,” said Robert Elfinger, a Walgreens spokesman.

An agent with insurance claims giant Sedgwick, representing Walgreens, also called the family to apologize and inquire about Lindsay’s status.

“Walgreens was sloppy,” Lindberg said. “The doctors told us we were lucky. Thank God.”

One of Lindsay’s prescriptions was for a diuretic called Lasix that drew liquid away from her lungs, enabling her to breathe more easily and drink a mixture of breast milk and infant formula. Another drug was digoxin, a steroid that made the baby’s heart beat stronger and faster to pump more blood through her body and compensate for the defect until surgeons could operate.

The pharmacy had stuck a Lasix label on a bottle of digoxin.

The baby has a ventricular septal defect, a hole between the left and right ventricles of her heart. Doctors initially wanted to wait and see if the defect – which occurs in about 1 percent of infants – would heal on its own.

But Lindsay’s weight and health faltered, and she needed surgery.

After the medication mix-up, surgeons cut open Lindsay’s chest and patched her heart. She is now home and recovering.

Nationally, the volume of prescriptions is staggering.

Pharmacies filled more than 3.8 billion prescriptions last year. Walgreens’ 237,000 employees filled about 617 million of those.

The company spent more than $1 billion in the past 10 years on safety programs to curb prescription errors, Elfinger said.

Among the initiatives is a move toward more electronic prescriptions. The federal government began offering financial incentives to doctors this year to submit prescriptions electronically.

The move is seen as a way to cut the number of errors due to tough-to-read handwritten prescriptions and reduce phone time between medical clinics and pharmacies.

The misuse of medications – excluding intentional drug abuse and suicide attempts – leads to more than 1.5 million Americans getting sick, injured or killed, according to a 2006 report by the Institute of Medicine.

Said Walgreens’ Elfinger, in a written statement, “We’re sorry this occurred and we apologized to the family. We have a multi-step prescription filling process with numerous safety checks in each step to reduce the chance of human error. We are investigating what may have happened in this case and will take appropriate actions to prevent it from happening in the future.”


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