Close call

A pharmacy misfilled a baby’s prescription with methadone – a mistake that was caught just in time

A five-month-old girl was almost given methadone after a pharmacy accidentally dispensed the wrong medication.

Omayma Pathan from Ontario in Canada told Global News Canada that she went to the pharmacy to get her daughter’s usual anti-reflux medication prescription filled.

She had been dispensed a bottle that looked exactly the same as her baby’s usual lansoprazole, but the label had somebody else’s name on it and stated the contents were methadone.

“Luckily I was literate enough to read, but in Brampton there are a lot of people who can’t read and write English. Can you imagine what would have happened?” she told news broadcasters.

Methadone is an opioid that is used to treat people dependent on heroin.

The safety and effectiveness of methadone in patients aged under 18 years has not been established.

Accidental or deliberate ingestion by a child may cause respiratory depression that can result in death, and even small doses of methadone can kill a baby or young child.

“All I could think about is I have a bottle of poison and I was about to feed it to my baby with my own hands,” said Ms Pathan.

“Our lives would have been shattered if I didn’t read the actual bottle.”

The usual bottle of medication (left) and the methadone that was mistakenly dispensed (right). Image credit: Global News Canada

This is not the first time a child’s prescription has been misfilled by an Ontario pharmacy.

In March 2016, Melissa Sheldrick’s eight-year-old son Andrew died after he received baclofen instead of tryptophan.

Ms Sheldrick has been an advocate for mandatory error reporting across Canada since that time.

“My heart is breaking all over again. The saving grace is that mom checked the label,” she said on Twitter in response to Ms Pathan’s recent story.

She encouraged people to “check your meds”.

The pharmacy chain responsible for the error reportedly responded to Global News, saying it had been a “considerable error, and one that absolutely should not have happened”.

It said it is “taking appropriate steps to prevent this type of unfortunate mistake from reoccurring”.

One in 10 errors reported to PDL involve incidents in the pharmacy where a person receives medication intended for another.

Consequences include serious harm to the consumer and professional risk to the pharmacist and pharmacy owners, says the organisation.

Read more about medication errors here

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