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'Wrong Dose' Prescription Error Investigated After Baby Sickened

POSTED: Monday, April 28, 2008
UPDATED: 11:42 am EDT April 29,2008

A prescription error that led to the overdose of a 3-month-old in Central Florida is one of several similar cases around the country, a Local 6 investigation has learned.


IMAGES: Baby Sickened, Statement From Walgreens

The report featured Central Floridians, John and Sharon Ruddell, who recently had twins.

When one of their infant daughters, Leah, contracted a sinus infection, the family filled a doctor's prescription for Histacol DM syrup at a Palm Coast Walgreens store.

After Leah took her first dose, the family realized that there was a problem. Leah became non-responsive after taking the medicine, according to her parents.

Then, the family said Walgreens discovered the error on its own and called the Ruddells.

"Two hours later, I get a phone call from the pharmacist at Walgreens and he explained that they misprinted the label," John Ruddell said. "It was supposed to be a quarter milliliter, not a quarter teaspoon."

The dose is six times the amount the girl should have been given.

"It was the scariest time of my life," John Ruddell said. "I didn't know whether my daughter was going to live or die."

John Ruddell said he called poison control and was told to get Leah to a hospital immediately.

"I prayed the whole way there just to keep her alive because she's my baby," Sharon Ruddell said.

Hospital records indicate that the baby had overdosed on the medicine, Local 6's Steven Cooper said.

Doctors were able to stabilize her and send her home.

"If she would have had that second dose, she wouldn't have woken up," John Ruddell said.

In a letter to the Ruddell family, Walgreens apologized for the incident but would not explain how it happened, Local 6 reported.

Two days after the overdose, Walgreens' insurer called to offer the family $2,000.

They declined, Cooper reported.

"Two-thousand dollars for almost killing my baby," Sharon Ruddell said. "It is almost like, don't bother."

The Ruddells decided to go public instead, Cooper reported.

"Don't get me wrong, I could use the money or $2,000," Ruddell said. "But if this will save someone else's life, they can keep their $2,000."

In a statement to Local 6, Walgreens admits there was an error and said, "We are addressing these issues with the pharmacist and taking appropriate action to ensure our safety procedures are always followed."

"It's not, 'Oops, I mispriced a candy bar,'" Ruddell said. "It's, 'Oops, I'm sorry. I nearly killed your kid' and that is not right."

"I'm sure there are many more mistakes like this that happen and maybe we don't hear about them," Sharon Ruddell said.

In a recent report filed by USA Today, four fatalities were linked to prescriptions filled at Walgreens since 2006.

The fatalities led to multimillion-dollar verdicts against Walgreen's -- $31 million for a misfiled prescription in Illinois, $28.5 million in Polk County and $6 million for a pharmacy error in Arizona.

Also, in Jacksonville, a case against Walgreen's has been settled out of court involving the death of Terry Paul Smith. Smith's prescription for methadone was labeled with the wrong dosage instructions, Local 6 reported.

Cooper said Walgreens is not alone when it comes to pharmacy problems.

Data from the Florida Board of Pharmacy indicates in one given year that there were 617 complaints filed against various pharmacies and 678 against individual pharmacists statewide.

In the same year, three pharmacies lost their license as did 13 pharmacists, with hundreds more facing disciplinary actions.

Watch Local 6 News for more on this story.
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