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Pharmacist Apologizes After Accidental Methadone Prescription Nearly Kills Boy

The family of a 7 year-old is suing, after he almost died when a drug mixup by his pharmacy left him accidentally overdosed on the wrong medication.  The pharmacist's mea culpa may not be nearly enough to avoid legal action and the threat of losing his license.

"He wasn't moving," is how the second grader's mother, Christina Torres, described the state she found her son Adrien Hernandez in one evening in July after she'd given him the prescribed dose of what she thought was Ritalin.  That's the brand name for the ADHD treatment drug whose clinical name is  methylphenidate.  

"He wasn't breathing.  He was just blue," Torres said about her son.  The reason for his grave state was that she had given her son another drug entirely, one meant to treat hard core drug abusers -- methadone.

The mixup was apparently due to two factors.  Pills of both medications are stamped with the letter "M," and both were distributed to Torres and her son in 10 milligram pills.  The Soundview, Bronx mom had usually gotten hexagon shaped pills.  But this time the pills were square.  She attributed it to a new generic prescription she'd recently filled.  It turned out to be hazardously wrong, even though the pharmacy had labeled her pill bottle as being full of Ritalin for her son.

She rushed him to the emergency room, where he vomited and received a system cleansing intravenous treatment.  He became well enough to talk minutes after arriving, but what he said was far from reassuring.

"He was saying, 'I'm scared.  I'm going away to someplace that's dark, Mom," Torres told PIX11 News. "'It's dark.   I'm scared."  She held him, touched him and talked with him, anything she could do to keep him from slipping back into unconsciousness.  

She also told the medical staff about the medication she had given her son.  They analyzed the pills, and the result gave Adrien's mother an even bigger shock.

"[They said], 'Ma'am, your son has been given methadone.  So basically, he's overdosing on methadone."

The drug is given to heroin addicts as part of their recovery from the intense illegal drug.  How this mistake could happen was for the pharmacist to explain.

PIX11 went to the manager of Felicity Pharmacy on East Tremont Avenue in the Bronx.  Naleem Thakkan said that he was not hiding from the mistake.

"I have remorse for the victim's family," Thakkan said.  "We don't want this to happen again."  

He said that his supply of the two drugs were kept together in the same drawer in the pharmacy, and that the lids of their nearly identical, white dispenser bottles were not marked to tell them apart.  He said that since the incident, the drug bottles are marked, they're kept apart from each other in the drawer and that they are triple checked for accuracy before being distributed.  

"I want to assure we are taking steps to prevent it from happening again," said Thakkan.  The fact is, however, that a similar mixup in 1999 killed a child who was just one year older than Adrien.  the situation was so severe that it prompted a nationwide warning from the FDA.  

Pharmacists like Thakkan are supposed to be familiar with the FDA precautions.  Overlooking them is what prompted Torres's lawsuit, which was filed in the Bronx on Monday.  

"We want people to know about this potential mixup," her attorney, Eric Buckvar, told PIX11 News.  "It's happened before and we don't want it to happen again."

The suit does not specify damages, but Buckvar said that in addition to the physical health scare, Adrien and his mother are seeking compensation for their  mental anguish and costs of caring for the boy in the future.  Any money the family receives from the lawsuit, Buckvar said, must be kept in a trust fund for Adrien until he turns 18.

 

Copyright © 2014, The Baltimore Sun
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