May 26, 2008

Pharmaceutical Nightmare

Have you ever seen someone's head actually explode? Mine came as close as possible last week and for those of you who have never seen me really mad, you missed a rare opportunity.

We picked up Evan's Epilepsy medication from the pharmacy and the next morning when we opened the bottle, we noticed the pills were a different color. Rob and I started studying the pills. Pink? They are supposed to be yellow. And aren't these a little bigger too? The label is correct, but these don't look right. I remember a lot of hoopla a couple months ago about an anti-epileptic med changing color but I thought it was one of Evan's old meds, surely I'd have remembered if it was the current one.

It was early, the pharmacy wasn't open, so we fired up the computer. Our suspicion was confirmed. The pharmacy gave us the WRONG medication, more specifically the wrong dosage. Instead of 300 mg Trileptal they gave us 600 mg Trileptal. If we had given this to Evan he would have had twice the dosage he's supposed to have and would very likely have ended up in the hospital with a toxic level of the medication is his system.

Back in December, when we were trying to get his medication levels straightened out after surgery, he had a toxic reaction to 450 mg of Trileptal that caused some pretty scary seizures followed by several days in the hospital. Last week we were poised to give him 600 mg. I don't even want to think about what would have happened "if".

The scariest part is that there are three different steps at the pharmacy to ensure something like this never happens. So three items were ignored in dispensing Evan's meds. The level of irresponsibility is astounding to say the least.


Mary said...

I'm just glad you and Rob are so on top of things and caught the error!

This is another reminder to everyone to take personal responsibility, but not everyone has the experience with the meds to catch an error like that. What if it had been a child's FIRST dose???

Had fun painting with you this weekend! See you soon,

Kelly O'Melia said...

Hi Mama Lisa,

I just wanted to let you know your blog has provided me with so much helpful information. My daughter is currently having the same surgery Evan underwent by Dr. Weiner in an attempt to stop her seizures. I feel like you and your husband did so much research and investigated so many medical establishments that you greatly reduced the amount of time we had to spend looking for the "right" doctor.

Thank you for making all of your experience publicly available. I pray Evan continues to do well and remain seizure free.

Kelly O'Melia

Mama Lisa said...


Thank you so much for posting to our blog. I'm so glad to hear that you found some of our experiences helpful. I will be thinking about your daughter -- she's in good hands with Dr. Weiner. He is such a gifted surgeon. When will your daughter be having surgery, or are you already in the midst of the hospital whirl-wind? Before Evan had surgery we found it helpful to talk to other parents who had been through the NYU experience before us and I'd be happy to share anything with you if you want. You can email me directly at