Family Says Pharmacy Error Nearly Killed Boy

By Chris Coffey
|  Wednesday, Feb 26, 2014  |  Updated 11:03 PM CDT
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Insiders say pharmacy mistakes are happening as staffs face increasing pressure to fill more prescriptions. Chris Coffey reports for NBC 5 Investigates.

Insiders say pharmacy mistakes are happening as staffs face increasing pressure to fill more prescriptions. Chris Coffey reports for NBC 5 Investigates.

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A 5-year-old boy from Crystal Lake mistakenly took a dangerous dose of an antipsychotic drug meant for an adult, according to his parents. They blame a pharmacy for the error.

"We almost lost our son. Could you imagine if I had given him more dosage?" said Robin Ahmed, the boy's father.

Ali Ahmed's name was listed on the prescription medication his mother brought home from Walgreens two years ago. His parents said they thought the prescription drug, which was labeled Haloperidol, was meant to treat allergies. It came in liquid form.

Ali took the medicine and slept nearly two days straight, his father recalled. And when Ali woke up to eat a cookie, his neck flared. Ahmed said paramedics were called to their home. He said the first responders thought the boy was choking. Luckily, Ali's neck flare subsided.

A few hours later, however, Ahmed said Ali started acting strange and fainted. His parents said they took Ali to his doctor, who told them to immediately go to the hospital.

"Later on we all find out this medication affected everything to him," Ahmed said.

The family said it learned the Haloperidol was meant for an adult who shared the same name as their son.

"What could we have done to prevent this?" Ahmed said.

His parents said Ali, now 7, appears to be physically fine. Still, Ahmed has noticed little things cause his son to cry.

"The trauma that he went through in the emergency room, he's still scared," Ahmed said.

Ahmed and wife recently filed a lawsuit accusing Walgreens of negligence. According to their complaint, Walgreens should have known from the prescribed dosage that the prescription was not for Ali. The complaint also accuses the pharmacy of failing to properly warn the family that Haloperidol is dangerous for children in the amount administered to Ali.

His parents said they fear Ali may suffer long-term effects.

"They should pay for this, all due respect," Ahmed said. "This is not right because we trust that logo."

Walgreens said it takes pharmacy safety very seriously but said it cannot comment on pending litigation.

"We are sorry this occurred and we have apologized to the family," said a Walgreens spokesperson.

Insiders from the country's second largest pharmacy chain, CVS, said mistakes are happening as pharmacy staffs face increasing pressure to fill more prescriptions.

"Rushing through them, you're going to miss stuff," said a current CVS pharmacist who asked not to be identified for fear of getting fired for speaking out.

NBC 5 Investigates obtained copies of internal CVS measurements sent to pharmacists. Performance grades are given for the number of flu shots administered and how long it takes to fill prescriptions.

Joe Zorek was a CVS pharmacist in Pennsylvania for more than 30 years. He filed a whistleblower lawsuit against CVS after he claims he was punished for complaining about company changes.

"It's McPharmacy, you know, get it done as quickly as you can and that becomes scary after a time," Zorek said.

In a statement, CVS/Pharmacy said it measures the quality and effectiveness of the services it provides to ensure it is meeting customers' expectations.

"Our systems are designed to help our pharmacists manage and prioritize their work to best serve their patients," wrote a CVS spokesperson.

Dr. Carmin Catizone heads the National Association of Boards of Pharmacy, which represents the state agencies tasked with ensuring pharmacy safety.

"If those metrics actually harm the patient or prevent the pharmacist from delivering the care they need to deliver, than those aren't the right metrics because they're not in the best interest of the patient," Catizone said.

Catizone said no one is keeping track of pharmacy mistakes.

"Unfortunately it's not mandatory and unfortunately we don't see much voluntary reporting from the pharmacies across the country," Catizone said. "Collecting the data is important because you need to have an idea of what the problems are from a system perspective."

But he said you can't just create a "treasure trove" of information for trial lawyers to seek-out.

"To make the system better we need two things to happen. We need to have honest and complete reporting and then we need liability relief for the pharmacies reporting this," Catizone said.

CVS said the health and well-being of its patients is their number one priority. Walgreens said it takes pharmacy safety very seriously and constantly works to improve quality, accuracy and service. Both companies tell NBC 5 Investigates they have a multi-step prescription filling process.

"Prescription errors are a very rare occurrence, but when they happen we do everything we can to take care of the patient's needs, including contacting their prescriber to address any health concerns. We also examine how an error may have occurred as a critical part of preventing errors in the future, so we encourage our pharmacy teams to report such incidents," CVS wrote in a statement.

Walgreens wrote, "If a prescription error happens, our first concern is for the patient's well-being. Following investigation of an incident, we work to prevent it from happening again."

Experts urge consumers to always double-check the prescription drugs they received.

Consumers can also report pharmacy mistakes to their state boards of pharmacy.

NBC 5 Investigates examined data showing the state of Illinois took action in the past two years against several pharmacists who either stocked expired medication or had improperly labeled medication.

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