Yukon Pharmacy Fills Wrong Dosage for Baby

Wednesday, January 21st 2009, 7:12 pm
By: News 9

By Kirsten McIntyre, NEWS 9

YUKON, Oklahoma -- A new mother said a pharmacy filled the wrong dosage of a prescription for her newborn baby.

Mindy Koenig said her six-month-old, Story, came down with a cold, which developed into a respiratory virus. Story sufferd from several ear infections as a result of the virus.

Story's father took her back to the doctor, who prescribed Albuterol for the child's wheezing and gave her parents specific instructions.

"You need to be very, very careful when administering this drug," Mindy Koenig said.

The side effects of an overdose include:

  • Nausea
  • Irregular heart beat
  • Convulsions
  • Death

"She pulled out a syringe and showed him the exact amount to give the baby," Koenig said.

The prescription was dropped off and filled at a CVS in Yukon. Koenig brought home her filled prescription, filled her syringe to the dosage written on the bottle and almost gave Story the medicine.

"I go to put it in her mouth and just as I'm about to squeeze it he says, ‘Wait, wait, that doesn't look right,'" Koenig said.

Story was supposed to get one and a half cc's of the medicine. The bottle was, misprinted, reading one and one half teaspoons. It was five times the amount the doctor had prescribed.

"Thank God he saw that," Koenig said. "If my husband hadn't been here, I don't know where my baby would have been. We may not have that baby this morning."

Koenig said she hopes others will realize mistakes happen, and when it comes to children parents can't be so trusting of their pharmacist.

"Make sure when they fill that drug that is what the pediatrician or doctor prescribed to you, because in this case, it saved her," Koenig said. "I'd love to save other people's lives."

Koenig said CVS admitted its mistake and offered to reimburse her for the $8 prescription.
She said it's not about money, but making sure this doesn't happen again.

CVS said it is now trying to determine how the mistake happened. It's also issued an apology to the family.


CVS/pharmacy Statement:

"The health and safety of our customers is our top priority and we have extended our sincere apologies to the Koenig family.   Our district pharmacy supervisor contacted the family last evening when we learned about this incident and was told that none of the medication was administered at a higher dose than was prescribed.  It is always a matter of good practice for customers to check their prescriptions, as the Koenigs did in this case, and to ask their pharmacist any questions they may have about their medication.

CVS has industry leading pharmacy systems and processes designed to enhance the safety of the prescription filling process.  In the rare event of a prescription error, we work diligently to learn what happened and take steps to prevent a further occurrence, which is what we are doing in this matter.  We recognize that any process involving people is not immune from the possibility of error or deviation from procedural controls, which is why we remain committed to continually improving quality measures to help ensure our pharmacists fill prescriptions safely and accurately.

Again, we offer our sincere apologies to the Koenig family. "