TEAM10: Family says pharmacy made a dangerous prescription mistake

Posted at 10:45 AM, Jul 19, 2018
and last updated 2018-07-19 13:51:25-04

'He kept laying around saying, mom, I'm tired but couldn't sleep'

An east county family is asking a pharmacy to change its protocols after they say the wrong dosage information on their child's prescription almost put him in the hospital.

This latest case is another example of errors that state officials might not know about. 

"I am angry," said Shannon Beasley.

Playing with his trucks or hitting home runs in his room is where you're likely to find three-year-old Michael.

"Michael does not lay around," she said. "If we can get him to sit for a 45-minute paw patrol episode that's a good day."

So when his mom noticed he was more lethargic, she knew something was wrong.

"He kept laying around saying, mom, I'm tired but couldn't sleep," she said.

'Wait, mam. Read that one more time'

Beasley said a doctor diagnosed Michael with an ear infection.

The doctor prescribed Cefdinir, an antibiotic used to treat infections. They had the prescription electronically sent to a Walmart pharmacy in El Cajon.

"My husband gets there, signs in, gets his prescriptions, brings it home," she said. "I gave him the first dose, later that evening I gave him the second dose because the bottle said two times a day."


Beasley said three days into the routine Michael wasn't getting any better. He was tired, refusing to eat, had diarrhea, and was not his normal, destroying-the-house self.

Beasley had enough and called the nurses' line. She said the nurse asked her to read the prescription and dosage information from the bottle.

"She's like, 'Wait, mam. Read that one more time,' and I read it to her again," she said. "It was four ml's (milliliters) twice a day, and she says, 'No, mam. The doctor prescribed four ml's once a day.'"

She says the instructions on doses per day were wrong.

"I was giving him more than what he, and I was the one making him sick," Beasley said.

'I feel like there is no room for error in this job'

She hung up the phone, contacted poison control and rushed Michael to a doctor.

Michael was severely dehydrated, but Beasley said stopping the medicine the day before was helpful. 

She called the Walmart pharmacy, then received a phone call from the company.

"Walmart's claim department contacted me with an apology and what not, but unfortunately, I feel like there is no room for error in this job. And luckily I took him off of this sooner, but if not, who knows what the outcome would have been," she said.

In a statement, a spokesperson for Walmart wrote:

"We work hard every day to ensure we live up to the high standards we set for ourselves and that our customers expect. We have quality control measures in place to help ensure that our customers receive the exact medications prescribed. In this individual case, we deeply regret this incident occurred despite our quality control measures. We have apologized to the Beasley family and continue to stand ready to work with them to resolve this matter. We take customer safety seriously and have reviewed our procedures carefully to avoid a similar incident in the future."

Team 10 discovered the California State Board of Pharmacy issues hundreds of citations to pharmacists each year for dispensing errors.

But those errors are only what the state knows about. In California, pharmacies are not required to report those errors.

In April, the head of the agency told Team 10 the board relies on consumer complaints and court settlements to identify wrongdoings.

"We strongly believe that pharmacists do not deliberately make errors," said Board of Pharmacy Executive Officer Virginia Herold. "If they do, that would be a formal disciplinary matter, and we would move very quickly to remove them from practice."

The board received more than 3,000 complaints during the 2016-17 fiscal year

According to information obtained by Team 10, the board received more than 3,000 complaints during the 2016-17 fiscal year. 

During that time, it issued more than 2,000 citations for pharmacist and pharmacy wrongdoings and referred more than 350 cases to the California Office of the Attorney General.

Herold told Team 10 pharmacies are required to keep records of all dispensing errors. 

After a mistake, the pharmacy must initiate a quality assurance review looking at what happened and who is responsible. 

After what happened with her son's medication, Beasley believes there's no room for error in a pharmacy.

The easiest way to prevent a dispensing error is to take the time to talk to your pharmacist, according to experts. 

If you want to learn more about pharmacists and disciplinary actions or to report a dispensing error, you can do that on the California State Board of Pharmacy website. https://www.pharmacy.ca.gov/consumers/complaint_info.shtml