Medication Without Harm: Real-life stories

Dora, a 79-year-old woman, developed distressing symptoms including uncontrollable shaking, head bobbing, and tongue darting in and out of her mouth. A lady who really liked her daily trip into town found herself housebound and wondering what was to be her fate.

Dora’s daughter took her to the general practitioner who said sympathetically that this was Parkinson’s disease and there was nothing to be done. In the course of the conversation, the doctor mentioned that the only Parkinson’s she had ever seen alleviated was drug-induced.

Upon returning home, Dora’s daughter happened to glance at her mother’s long list of medications and had a moment of inspiration. She returned to the doctor and asked, "Considering the number of drugs she is on, is there any possibility this might be drug-induced Parkinson’s?". The doctor said the only way to find out was to take her mother off the medications.

Unaware that it can be risky to remove patients abruptly from their medications, Dora’s daughter stopped all her mother’s medications without further consultation. Fortunately for Dora, no permanent harm was done. After a week of withdrawal symptoms, including hallucinations and disordered thinking, all Parkinson’s symptoms disappeared, never to return. Dora was able to resume her usual daily trip to town and return to an independent life.

Taking a large number of drugs without regular medication reviews can have a devastating impact on quality of life and patient safety, especially in older people. Patients and families should make a practice of routinely going over the need for all medications with their health care providers and should be cautious about trying to stop medications without medical supervision.

*The names and photos used in this story are not real, but the story is based on true events. 

Eight-year-old Buddy was a lively boy with a beautiful laugh. Because of a sleep disorder, he took medicine every night to help keep his sleep cycle regulated. One night his mother gave him his medicine as usual and put him to bed. When his father went to wake him in the morning, Buddy was dead. Medics told Buddy’s parents that their child had been dead for hours. Months later, an investigation by the coroner revealed that instead of his usual medicine, L-tryptophan, Buddy had toxic amounts of a powerful muscle relaxant drug called Baclofen in his system. Buddy had died from a medication mix-up.

Upon analyzing the medicine remaining from Buddy’s prescription, the coroner found that the amount of medicine was precisely the amount required to produce the L-tryptophan mixture – but it was the wrong drug. Someone in the lab had mistakenly used Baclofen powder instead of L-tryptophan powder. The resulting liquid contained enough Baclofen to kill an adult, but it looked and apparently tasted the same as the L-tryptophan mixture. Once the mistake was made, it was impossible to tell the difference.

Buddy’s parents have begun a campaign to require reporting of medication errors to a database in the province they live in, and they hope that other provinces will follow suit. While pharmacy errors are believed to be rare in their high-income country, the actual number and type are not known because only one province now has such a requirement. “I think that when there is transparency, training can happen, review of policy and procedures can happen, intervention can happen”, Buddy’s mother said. “Nothing can bring Buddy back to us. However, in his caring spirit we want the laws to protect all people,” she concluded.

*The names and photos used in this story are not real, but the story is based on true events.

A woman took her 88-year-old mother, Naila, to the doctor. Naila had fractured her back six weeks earlier, and oxycodone had been added to the more than 10 other drugs she was already taking. Naila and her daughter were pleased that Naila’s back now appeared to be healed. To their surprise, the doctor did not propose discontinuing the oxycodone, but instead said she would place Naila on a pain management plan, as she was on so many medications. Naila’s daughter questioned this, as the oxycodone had originally been prescribed as a six-week course, and Naila no longer seemed to be in pain.

Naila’s daughter asked the doctor to review her mother’s medications before making any decisions. Starting at the top of the list, she asked the doctor the name of the first drug and the reason it was prescribed. Then she turned to her mother and asked if she still had that medical problem. Her mother said no. The doctor removed the drug from the prescription list.

Together the three of them went through the list, one drug at a time. As they went over each medication, they discovered that it was no longer needed and the doctor removed it. In the end only one drug was left. Naila now takes one drug daily and is very healthy.

Naila’s daughter asked her mother why she kept taking the drugs after she no longer had the conditions for which they had been prescribed. Naila said she continued to take them because the doctor continued prescribing them.

It is easy for a patient to build up a long list of drugs even after they no longer have a reason to take them. A regular medication review is an essential part of good practice for preventing unneeded treatment and potential harm.

*The names and photos used in this story are not real, but the story is based on true events.

Martha, the eldest in a family of five children, had low levels of potassium in her blood. This condition had been managed for years by giving her extra potassium.

Then, as a young nursing student, Martha developed mood swings that were diagnosed as bipolar disorder. She was prescribed lithium. Martha and her mother researched the drug and concluded it was safe. Martha had not been told, however, that recent tests indicated she had a congenital heart defect, or that a warning had been put in her medical file advising against prescribing lithium. She did not know that giving lithium to someone with low potassium can affect the heart.

As Martha began taking lithium her moods became more stable, but she started having spells of racing heartbeat. A doctor dismissed these symptoms as panic attacks and her lithium dose was increased.

Two weeks later, her father found her lying on the floor beside her bed where she had died during the night. She had not been able to get to the bedroom door to call for help.

Martha was just 22 when she suffered a fatal cardiac arrhythmia. Martha’s parents scoured her medical records to piece together the events that had led to their daughter’s death. They learned that a psychiatrist, knowing of Martha’s low potassium, had written the lithium warning in her chart. But a more junior doctor ignored the warning and prescribed the drug without mentioning the concern to Martha. They also discovered that tests had confirmed Martha's heart defect a year before she died. The heart doctor had never read the tests because it was his practice to wait for the patient’s return visit before reading the tests. Assuming that “no news is good news”, Martha had not made a follow-up appointment. 

A coroner’s investigation later confirmed that Martha had died of an adverse drug reaction, and that the heart defect, had it been communicated, would have been reason not to prescribe lithium. 

Poor communication among doctors and between doctors and patients is a common cause of medication errors. Patients should be informed of all potential complications before starting drug therapy.

*The name, photograph and contents of this story are true, published with permission from the family.

A couple took their two-week-old baby girl, Zoya, for a routine check-up. The paediatrician ordered two injections of vitamin K. At the clinic pharmacy, Zoya’s father was given two vials of medicine to take to the nurse for the injection. The paediatrician was on the telephone, but made a hand gesture to the nurse to indicate just one injection. The nurse gave the baby one injection and returned the second vial of medicine to the parents.

The baby cried loudly and continued to cry after the parents put her in the car. When she suddenly stopped crying, her parents realized she was no longer breathing. They turned the car around and raced back to the clinic. The father took Zoya in his arms and ran into the clinic, where the staff immediately began CPR. Although they were able to resuscitate her, the baby girl passed away later that afternoon.

As the grieving parents tried to understand what had happened, they looked at the vial of medicine they had remaining. It said EPINEPHRINE. They realized Zoya had not been given vitamin K as they had thought. They later learned that the dose on the epinephrine bottle was dangerously high for a small baby like their little girl. Clinic staff told them that the vitamin K and epinephrine bottles were similar in size and colour and were easy to confuse.

Look-alike packaging is an ever-present danger in the dispensing of medicines. Health care providers should remain vigilant and follow protocols to ensure that similarly packed medicines are not confused.

*The names and photos used in this story are not real, but the story is based on true events.

A woman went to the pharmacy to fill prescriptions written by two different doctors for two different family members. One prescription was for her daughter, Mila, who was pregnant with her first child. The other was a high-dose cholesterol medication for her 60-year-old husband.

The pharmacist prepared the two medications and put a sticker with the patient’s name on each box. But he accidentally reversed the stickers, putting the father’s name on the daughter’s prescription and the daughter’s name on the cholesterol medication. Mila took the cholesterol medication at the high doses written on the label and lost her baby as a result.

It is important for pharmacists and patients to double-check to be sure there are no errors and that the medication the patient is taking is the one that has been prescribed.

*The names and photos used in this story are not real, but the story is based on true events.

A 54-year-old woman was given high doses of steroids to suppress her immune response and prevent organ rejection after a kidney transplant. After 3 months of heavy doses of steroids she began to pass stool through the vagina. She was seen by a multidisciplinary team consisting of a kidney transplant surgeon who was also the senior urologist, a nephrologist, a senior general surgeon, and an obstetrics and gynecology consultant.

The medical team asked the senior radiologist to do a pelvic MRI. His report revealed that the patient had developed an abnormal connection called a fistula, a passage between the bowel and female reproductive system. The radiologist believed this was due to the high steroid doses the patient had been taking and recommended decreasing the dose. A review of the patient’s medical record showed that the original doctor had miscalculated the steroid dose, resulting in overdose. Another doctor who also reviewed the case commented that fistulas can be among the side effects of this medicine when it is given at high doses. Several years after her transplant, the patient died of severe infection. 

Even if the fistula was not the direct result of her steroid medication, this patient received a dangerous overdose that was continued over a long period. It is important to calculate dosages carefully and to review them regularly for accuracy.

*The names and photos used in this story are not real, but the story is based on true events.

Oneida, a 13-year-old girl, began having spells of numbness in her arms and legs. A neurologist diagnosed her as having a rare form of migraine that caused numbing instead of headaches. He prescribed a drug in the triptan family, a class of drugs that alleviates migraine headaches by constricting the arteries.

Several days later, Oneida suffered a massive stroke that left her in a coma. After the stroke, doctors realized she had Moyamoya, a disease that causes narrowing and blockage in the arteries at the base of the brain. Her numb spells were not migraines, but mini-strokes. By constricting her arteries, the triptan had turned her mini-strokes into a full-blown stroke.

The medical team met with Oneida’s mother and informed her that her child was brain-dead. Oneida’s mother said she could not accept this. “What do you want us to do?” asked the doctors. “Give her time,” replied the mother. Two weeks later, Oneida opened her eyes. Two weeks after that, she regained full consciousness.

With intense physical therapy, Oneida slowly improved. After five months she was able to leave the hospital and return to school. Her mother quit her job and her brother gave up after-school activities to care for her. Family, friends, and even complete strangers chipped in to help the family survive financially. Nearly two years after the stroke, Oneida entered high school walking with only a leg brace. Although she still has severe disabilities, she has graduated from high school and enrolled in college.

The migraine drug this young girl had been given was labelled with clear warnings that it should not be taken by patients with a history of stroke or mini-strokes. Nothing had been done to rule out mini-strokes as a cause of her symptoms. It is important for health care providers to be certain they have the correct diagnosis before prescribing high-risk medications.

A woman in her 80’s, Jolene, went to the eye doctor because of reduced production of tears, which was causing pain and extreme sensitivity to light. The doctor diagnosed the problem as age-related dry eye and prescribed a medication to stimulate production of tears.

Jolene’s daughter then discovered that her mother had been taking an over-the-counter antihistamine previously recommended by another doctor, although she did not have a serious problem with recurring allergies. Researching online, the daughter found information in the national library of medicine that linked the antihistamine to reduced tear production. Her mother discontinued both medications and her tear production returned to normal.

Families are important partners in medication reviews. There are thousands of medical conditions and thousands of drugs on the market, and doctors are not always in a position to consider every possibility for every patient. Research by patients and families, properly done, can help patients prepare to discuss with their doctors whether a symptom might be a drug side effect.

*The names and photos used in this story are not real, but the story is based on true events.