A mix up at a pharmacy proved nearly fatal after a six-year-old’s ADHD medication was accidentally swapped with a lethal dose of opioids.
Sarah Paquin, a mother-of-three from British Columbia in Canada, said her son Declan had been taking dextroamphetamine to treat his attention-deficit hyperactivity disorder for years.
Paquin picked up his prescription as she always did from a local Shoppers Drug Mart pharmacy, and didn’t notice anything unusual.
However, when her husband David went to give Declan his daily medication the next morning, he noticed the pills were a different color.
When he checked the label on the bottle, he realized it contained a high dose of the opioid hydromorphone and the name on the prescription was of a woman the family didn’t know.
Hydromorphone is around four times more potent than morphine. The medication has the possibility of causing life-threatening breathing problems.
This risk is particularly high for children due to their smaller size and weight. ‘It’s just terrifying. We put our trust in these local professionals to be upholding their end,’ Paquin said.
She’s urging people to double-check their medication labels.
Sarah Paquin from Comox in British Columbia said her six-year-old son Declan had been taking dextroamphetamine to treat his ADHD for years. But she was horrified when his pills were mixed up and he almost took a drug four times as powerful as morphine
The Paquin family want to make their story public in a bid to warn other parents about the importance of being vigilant
She told CTV News: ‘[The pills] were in his hands.
‘He would have had this high dosage of morphine and been sent off to school, unknowingly… I think this was entirely avoidable.’
Mr Paquin immediately returned the medication to the pharmacy, where the pharmacist gave him a refund but she was unable to find the correct prescription.
The order had to be refilled.
Commenting on the matter, a spokesperson for Shoppers Drug Mart’s parent company, Loblaw PR, told DailyMail.com: ‘Upon review with the store, we have learned this was a case of human error, one that never should have happened.
‘We have controls in place to minimize risks like this – where the patient was handed the wrong prescription bag – and the associate will review these with employees to avoid a similar situation in the future.
‘The owner of this location has reached out to the patient’s parents to apologize for any undue stress this may have caused, and to outline the corrective steps.’
The Paquin family say they have also been informed the pharmacist responsible for the error has been suspended.
They now want to make their story public in a bid to warn other parents about the importance of being vigilant.
Mrs Paquin says: ‘[Patients and parents should] double, triple, quadruple-check every prescription you pick up, whether you’ve been going to that pharmacy for years, whether it’s a medication you’ve been on for years.’
The Paquins have also filed a complaint with the College of Pharmacists of British Columbia about the incident.
The organization regulates all pharmacies in the province.
The FDA receives over 100,000 reports related to medication errors annually, with these contributing to up to 9,000 deaths.
In 2022, a former Tennessee nurse was found guilty of criminally negligent homicide in the death of a patient who was accidentally given the wrong medication.
RaDonda Vaught, 37, was also convicted of gross neglect of an impaired adult in a case that fixed the attention of patient safety advocates and nurses’ organizations around the country.
Vaught injected the paralyzing drug vecuronium into 75-year-old Charlene Murphey instead of the sedative Versed on December 26, 2017.
