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Doctor prescribes wrong dose of ADHD drug, causes death of grade-school child

It's dangerous for patients when physicians don't read or follow drug maker dosage guidelines

One of the common prescription medication errors occurs when a doctor, physician’s assistant, or nurse practitioner prescribes the wrong dosage of a medication. In some cases, this can be life-threatening.

That’s exactly what happened to an elementary-school boy whose physician wrote a new prescription for a drug to treat his attention-deficit hyperactivity disorder (ADHD).

Many medications, like this one, instruct prescribers to calculate the correct dosage based on the patient’s weight in kilograms. There’s often one set of numbers for adults and another set of numbers for children.

For this drug, the manufacturer recommended beginning children at a dose of 25 mg per day, gradually increasing the dosage by 2.5 mg per kilogram of the patient’s weight each day, up to a maximum dosage of 50–75 mg per day.

The reason for this reduced dosage should grab anyone’s attention, let alone a prescribing physician: ECG (electrocardiogram or heart rhythm) changes have been reported in pediatric patients with doses exceeding this amount. In other words, it’s important to dose this medication correctly, or the patient can develop a fatal heart arrhythmia.

In this case, though, the prescribing physician later admitted that he hadn’t bothered to review the manufacturer’s recommendations for this drug. Instead of starting this little boy on 25 mg of this medication each day, he ordered 50 mg. Instead of gradually raising the dosage to 50–75 mg per day, as the drug maker specified in the product packaging insert, the doctor wrote the prescription to go up to a maximum daily dose of 200 mg per day—that’s over 3 times the recommended dose!

Tragically, once the boy reached the dosage that his doctor ordered, he developed a heart problem called ventricular fibrillation, a deadly condition where the heart has disorganized electrical activity and stops pumping blood. He was taken by ambulance to a hospital, but they couldn’t resuscitate him, and he passed away at a tender young age.

While there’s no doubt in my mind that the prescribing physician was the principal party responsible for this boy’s needless death, I also think the pharmacy bears some fault. Pharmacists are highly educated and trained on the way medications work and are responsible for reviewing prescription dosages.

When a prescription comes in that dramatically exceeds the normal recommended dosages, the standard of care often requires pharmacy staff to contact the prescribing provider for clarification. Sometimes, a doctor has a specific purpose in mind and makes a conscious decision to order a higher dose than normal. If that’s the case, then it’s fine under the standard care for the pharmacy to dispense and fill the prescription. On the other hand, physicians and mid-level providers sometimes make dosage mistakes, and that’s why it’s important for the pharmacist and pharmacy staff to speak up and ask appropriate questions.

If you or a loved one has been seriously injured because of medication errors, contact a top-rated experienced Houston, Texas medical malpractice attorney for help in evaluating your potential case.

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him by calling 281-580-8800 or emailing him right now.


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