Patient dies from prescription overdose after pharmacy error

A New Brunswick patient died after overdosing on a muscle relaxant because of a drugstore’s prescription error, according to a new ruling reprimanding a Moncton pharmacist.

Peter Ford was ordered to pay $13,000 after the patient was given medication containing five times the labelled concentration of baclofen.

A New Brunswick College of Pharmacists ruling says the unidentified patient was a resident of a long-term care home.

“The coroner implicated baclofen overdose as a contributing factor in the death of the patient,” said the ruling this week from the college’s complaints committee. “This error was the result of a lack of safety systems rather than attributable to a single member of the pharmacy team.”

The drug had been administered for a week in doses of 10 mg/ml, rather than the labelled 2 mg/ml, before a nurse realized the baclofen suspension appeared different than usual.

The ruling said Ford’s Pharmacy had no training or policy to double-check dosage, and was not recording drug error nearmisses, so the college was unable to tell if there had been similar problems previously.

The college gave the pharmacy tools to document errors and near-misses, but said staff used them less over time.

“The complaints committee considered Dr. Ford’s initial laxity in managing quality assurance measures and subsequent inaction to address them to be an abrogation of responsibility to patient wellbeing and therefore reprimands him,” said the committee’s ruling. “Dr. Ford has important responsibilities to ensure the safe and effective practices within that environment.”

The college said it will “intensively monitor” the pharmacy to ensure improvements are made.

It added the complainant who brought the case to the college “expressed satisfaction” with the ruling and hopes it helps prevent future errors.