March 27, 2008

Risperdal Kills Nursing Home Patient

An Illinois nursing home faces fines from the state after giving an unidentified patient the atypical antipsychotic Risperdal at 10 mgs. a day. I've been around mental health issues for years and I think the highest dose I've ever heard of anyone getting of Risperdal was 8 mgs. a day and that was for a severely psychotic person.

What may have happened in this case is that the pharmacy order was written for 5 mgs. of Risperdal twice a day, so you have to suspect that someone in the pharmacy missed a decimal point--as in .5 mgs. of Risperdal twice a day. Either way, a nurse or someone else should've caught the mistake since 10 mgs. of Risperdal makes no rational sense for anyone, especially a nursing home patient.

The patient received 19 doses of 5 mgs. in January 2007 and died the next month of a heart attack.

Posted by Philip Dawdy at March 27, 2008 09:54 AM
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Posted by: Bill at March 27, 2008 10:48 AM

Not to forget antipsychotics carry a warning regarding use for elderly patients! this concerns me, because the drug is being given to "calm agitation" in most cases. Human error in my opinion is not with who read a script wrong it's with the doctor who wrote it.

Posted by: Stephany at March 27, 2008 12:21 PM

You forget Philip...I was on 11 mg of Risperdal...you've been shocked by it a couple of times now!! Not shocked enough...anyway...I do believe I hold the record for the most Risperdal ever...and I worked with the so-called "severe and persistently" mentally ill-- the most I ever saw was 6 mg and usually the max was 4 mg.

Posted by: Gianna at March 27, 2008 04:35 PM

3 mgs. is the maximum safe dose of Rispedal, when it first came out doctors went up to 6, but that's a long time ago. Whoever was getting 8 was at risk. This death is so sad.

Posted by: Alison Hymes at March 27, 2008 06:05 PM

i may as well chime in here and remind everyone my daughter was placed on risperdal at age 11 in 1999! imagine at that point her paste white, sweating and nurses running to tell the doctor. i thought she was dead. i had NO idea about these drugs then. and we know it wasn't approved for OCD in 11 year olds a decade ago!

Posted by: Stephany at March 27, 2008 08:51 PM

Wow-- thats horrible. I am actually a paralegal at a medical malpractice law firm, so this doesn't exactly shock me. There is actually a new push in the medical community to have doctors enter their orders electronically so that decimal errors and mistakes don't happen as often. I think that would be a very good idea considering the deadly consequences of medication errors.

Posted by: Amber at March 30, 2008 05:38 PM

amber, doctors can still type in errors.it's an efficient method, that already is in place and contains the same human error stats as written scripts.

Posted by: Stephany at March 30, 2008 11:11 PM

I worry that typing in errors is at least as easy to do as writing errors (or mistakes caused by illegible hand writing). The solution would seem to be obvious. When you get a prescription ask the pharmacist what's its for and if the amount you are prescribed seems reasonable. If not, request that s/he call the doctor's office to verify the prescription. Of course even this doesn't guarantee an error free prescription but it's close. I think every prescription drug a person takes should require two long conversations specifically about that drug, one with the doctor, and another with the pharmacist.

Posted by: Sally at March 31, 2008 06:31 AM

One of my doctors has the internet click and send direct to the pharmacy; another hand writes scripts. The other day my pharmacist complained about the internet electronic scripts because there is no way for them to take a double take on it. Whereas he said when he sees handwritten, whether it's not good writing or not, it's easier to detect an error. He said they have to take the electronic one for what it says,and as a pharmacist his complaint was interesting.

I always check the pills, read the label etc. learned the hard way after taking home someone elses medication once, and yes I reported it.

Unfortunately vulnerable populations cannot often check their medications and rely completely on nursing or doctor staff for their safety. That's the worst part about this story.

Posted by: Stephany at March 31, 2008 11:17 AM

Stephany-- its a good thing you were looking out! Unfortunately, people just don't pay attention or think it can happen to them. We have had a few cases come through the office where a script error happened and they basically said that they never even thought to check for mistakes....

Posted by: Amber at March 31, 2008 12:59 PM
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