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Prescription Drug Death Caused By “Daily” Rather than “Weekly” Prescription Error. Who Is Responsible?

October 17th, 2014

A mistake in the dosage labeling of a commonly prescribed medication resulted in the tragic death of a 72-year old man in Dunedin in the country of New Zealand. Now investigators are trying to determine where the fault lies with this prescription drug death.


According to coroner C. J. Devenport, Kenneth Jeffrey Douglas died of gastrointestinal hemorrhage caused by an overdose of methotrexate.  The coroner called the death preventable, and though he acknowledged that the original mistake was made by the physician who typed up the prescription, he believes that the pharmacist should have caught the error and corrected it.


Douglas physician at Dunedin South Medical Centre is Dr. Anne-Marie Tangney. When the doctor originally typed up the prescription she made the error of typing the word “daily” onto the prescription rather than “weekly.” Despite the fact that the physician made the error, Mr. Devonport says that part of the job of the pharmacy and pharmacist is to provide a check and balance that catches these errors and protects the patients.  According to the coroner, an investigation by New Zealand College of Pharmacists executive board member Bernie McKone found no less than eight separate instances during the process of filling the prescription when the error could have been discovered and amended.


Methotrexate is a drug that is prescribed for a number of different conditions, including cancer and severe psoriasis. In Mr. Douglas’ case, it was prescribed for rheumatoid arthritis, a condition from which he had suffered for over twenty years. He was originally prescribed the medication in 2010, but was taken off of the drug when it was shown that his liver was showing signs of negative side effects. Methotrexate patients are routinely monitored to ensure that the drug is not causing them problems with either their liver or their bone marrow.


Following the return of normal liver function, Mr. Douglas was put back on the medication at a reduced dosage of three 2.5 mg tablets, to be taken once a week. The physician indicated that she had believed he had understood the drug was to be taken weekly rather than daily, but acknowledged her own error in not having double checked the form before signing it. Mr. Douglas’ immune system quickly shut down after he began taking the increased dosage.  In response to the case, Mr. Devonport also suggested that the Royal New Zealand College of General Practitioners advise physicians to specify a day of the week on which to take weekly medications in order to prevent confusion in the future.


“Unichem South City Pharmacy failed to adequately provide those checks. Had pharmacists and staff at the pharmacy done so, Mr. Douglas’ tragic death may have been prevented,” the coroner said. Following his decision, Devenport referred the incident to the Ministry of Health medicines control team with the suggestion that the pharmacy’s procedures be reviewed. The Pharmacy Council had already responded at the time of the 2012 death, placing a counselor into the pharmacy in order to provide both mentoring and assistance to the dispensing pharmacist, as well as to observe and gather information about their abilities and processes.

The review that was instituted by the New Zealand College of Pharmacists indicated that the pharmacist involved in the incident was competent following the mentoring.



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Gavin P. Lentz, Esq.
Bochetto & Lentz

Gavin Lentz (right) was selected as a "Super Lawyer" for 2006-2009 and 2010-2015 in New Jersey by Philadelphia Magazine. He has also been selected as a "Super Lawyer" by Philadelphia Magazine and the Legal Intelligencer in 2004, 2005, 2006, 2007 2008, 2009, 2010, and 2011 - 2015.

On September 16, 2002 Mr. Lentz was selected as one of the top 50 lawyers in Pennsylvania by the Legal Intelligencer.

He has made many television appearances, including on Fox News, The Today Show, Inside Edition, and The Phil Donahue Show.

Mr. Lentz is a member of the American Trial Lawyers Association and the Million Dollar Advocates Forum.

As a former prosecutor, he knows how to aggressively go after large pharmacy chains to prove the facts necessary to protect your loved one's rights.

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