A West Shore couple is warning other parents about the regulation of pharmacists after their son was given sleep medication that was 14 times the prescribed dose.
The College of Pharmacists of B.C. investigated and confirmed that mistakes had been made but did not make a public announcement of its findings or publicly advise other pharmacies. It’s a lack of transparency the NDP government says its recently passed Health Professions and Occupations Act will change.
Brent and Lindsay Wilson are speaking out because, they say, regulatory colleges and oversight organizations need to take more responsibility when mistakes are made.
As it is, Brent said, there is no warning for other parents performing due diligence.
“We feel it’s just so wrong that if you go to the B.C. College of Pharmacists website, there’s no record of this for the next person.”
Their son, five-year-old Eli, has autism, is non-verbal and cannot swallow pills. He takes clonidine to prevent sleep deprivation that brings on seizures.
In February 2021, a mistake was made compounding their son Eli’s sleep medication into an oral liquid suspension.
After 12 hours of sleep, Eli was near impossible to rouse and in a seeming drugged stupor. A video taken 16 hours after he was given the first dose shows him falling asleep while standing.
His heart rate dropped to 55 from a resting rate of 90. Eli was taken to Victoria General Hospital’s emergency department on the advice of his pediatrician.
The Wilsons wanted to have the liquid clonidine tested so they would know if Eli had been overdosed or if he had another medical condition.
Lab tests done by a Vancouver firm and viewed by the Times Colonist indicated the medicine dispensed was “fourteen dose equivalents” of what had been prescribed.
The saving grace, said Brent, was that the dose contained a mix of the last drops of medication from an existing prescription and some from the new, much stronger prescription.
“It’s only dumb luck that it wasn’t [entirely made up of the] new prescription,” said Brent. “He could have been in critical care at Children’s Hospital — he could have had the worst-case scenario.”
The Wilsons took their concerns to the College of Pharmacists of B.C. An investigation by the college’s inquiry committee determined that the pharmacy did not have standard policies or procedures for compounding medications, and that the dispensing pharmacist didn’t execute a final check of the drug.
The “error was likely due to human error when weighing the active ingredient needed for the compounded prescription,” the committee said.
The pharmacists involved agreed to having an external expert help develop policies and procedures, and to complete course work on preventing medication errors. Pharmacy staff were also expected to take part in an education session and write about what was done incorrectly.
There was, however, no discipline or fines for the pharmacists and the decision was not made public.
The complaint identified the pharmacists involved as Ennreet Aujla, manager of the Forbes Pharmacy in Langford at the time, and Quin Andrew, who prepared the medication.
The pharmacy manager did not return a call for comment.
Elyse Sunshine, a Toronto-based lawyer who represented the pharmacists through the complaint process, said pharmacists cannot comment on a specific patient due to privacy and confidentiality laws.
Sunshine said the Health Professions Act requires that the college publish the most serious outcomes, such as when restrictions are imposed on a pharmacist’s practice or when there is a discipline hearing for misconduct.
In other situations, where the outcome is “less serious” or no action is taken, there is no requirement to publish anything, said Sunshine.
The Wilsons escalated their complaint to the Health Professions Review Board. The board’s findings were not made public either.
Health Minister Adrian Dix, in an interview, said changes in the Health Professions and Occupations Act will bring more transparency to the process.
“One of the significant groups that called for this transparency were members of the media who dealt with these stories and families who dealt with issues around colleges,” said Dix. “Contrary findings are published and are made public under the new Health Professions Act.
”This is one of the reasons we did Bill 36; four years of process, massive public involvement in that process, the longest legislative debate in my time in the legislature and we’re now going to be implementing it and I think it responds to some of the concerns expressed in this case and a number of other cases.”
The province is on track to implement the new legislation over the next year, said Dix.
The experience weakened the Wilsons’ trust in the prescriptions they are giving their child. For weeks, Eli was afraid to go to bed. His parents now give Eli micro doses of his medication in intervals to evaluate his reaction.
“Don’t just blindly trust that the prescription you get is accurate — especially when you’re dealing with compounds. It’s just more involved and more complicated,” Brent said.
The couple moved to a pharmacy that crushes pills into a liquid suspension instead of scooping powder from a batch and compounding it into a liquid suspension.
“Every time we get a new prescription, I mean, it’s nerve-wracking,” said Brent. “We check Eli’s heart rate then his blood oxygen to see if it is showing any reason to be concerned. And at that point if it looks good, then we feel more confident giving him the new prescription.”
Medication had been subject of previous warnings
In 2011, the Institute for Safe Medication Practices Canada issued a safety bulletin relaying three reports of children harmed due to errors during the preparation of oral clonidine.
In each case, the pharmacy used clonidine powder (in containers labelled by weight, in grams) and there was a mixup during the conversions among grams, milligrams and micrograms, and the concentration ended up being greater than intended.
The bulletin recommends using tablets labelled in milligrams, “which reduces the complexity of converting powder weighed in grams to a dose prescribed in micrograms.” It also advises independent double checks.
The Alberta College of Pharmacy issued a similar warning for pharmacy technicians compounding and dispensing oral solutions of clonidine for pediatric use in September 2020.
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