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Pharmacy Makes Another Potentially Dangerous Prescription Mistake

POSTED: 5:01 pm EST February 18, 2005
UPDATED: 5:33 pm EST February 18, 2005

Channel 9 has learned a Saint Cloud pharmacy has made another mistake. This time, a mother is lucky that the medicine she gave her baby wasn't more dangerous. CVS admits a pharmacist in Saint Cloud put the wrong directions on a medicine bottle. Doctors say the mistake put the child's life in danger.

The child's mother says this should be a warning to every parent out there to talk with the doctor and know what your child should be taking. In this case she didn't, and her son is the one who suffered.

"I thought maybe I had read the bottle wrong or I had made the mistake, until I came home and looked at the bottle," says Holly Kohler.

The bottle in question was a prescription for liquid Zantac. It clearly says three-quarters of a teaspoon twice a day. That's exactly what Kohler gave her baby Alex.

"I wish I knew what I was looking at when I turned in the prescription. Then I would have known they made the mistake before it even happened," Kohler says.

Instead, she found out at her son's next doctor's visit a month later. It should have been three-quarters of a milliliter, meaning she was giving her child our times the dosage twice a day for a month.

"His doctor told us we were lucky he was alive. It could have killed him giving him that much more," says Kohler.

Channel 9 couldn't reach Alex's doctor to verify that, but another doctor confirmed Alex had a higher risk for seizure or stroke while on the medicine.

"There's really nothing I can do about it, because I can't change what happened," Kohler says.

But she wanted the CVS Pharmacy, which filled the prescription, to take some action. She never heard back from them.

"The fact that that pharmacist is still working there bothers me, because this could happen to someone else and they wouldn't even know," Kohler says.

Channel 9 has learned that pharmacist had only been licensed in Florida for 28 days when she made the mistake. CVS told Channel 9 it's investigating.

"I'm wanting people to realize pharmacists are making mistakes to double check what they're getting," Kohler says.

Late Friday afternoon, after Channel 9 called CVS, a representative from the company did contact the Kohler family to apologize for the mistake.

As of now, the family has not contacted an attorney, but they are considering it.

There was a similar case involving the same CVS Pharmacy in Saint Cloud in October 2003. A pharmacist accidentally transcribed a one-year-old boy's name onto someone else's prescription. The mom was expecting a liquid antibiotic, but instead got hydrocodone in the pill form. Fortunately, the boy's mother caught the mistake before she gave him the painkiller.


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