A Comox couple is warning other parents to double check their children’s prescriptions after a pharmacy wrongly dispensed opioids for their nine-year-old instead of ADHD medication.
Sarah Paquin, mother of three young children, said the medication mixup could have been catastrophic for her son.
“As a parent, you worry enough as it is, and then to have such a close call like that, it really hits home.”
Paquin said she went to the Shopper’s Drug Mart pharmacy on Guthrie Road in Comox on May 28 to pick up her son’s medication — dextroamphetamine, a stimulant used to treat Attention Deficit Hyperactivity Disorder.
She said the employee had difficulty finding her son’s medication.
The employee asked for the boy’s name multiple times, and initially couldn’t find his name in the system, Paquin said. Once she dispensed the medication, the employee didn’t read over the label or confirm information, as is the usual custom, the mom said.
The next morning, Paquin’s husband, David Paquin, hesitated before giving his son the medication, noting the pills were a different colour.
When he checked the label, he saw the drug was the painkiller hydromorphone, which goes by the name Dilaudid. The patient’s name on the hydromorphone label was a woman they didn’t know.
Hydromorphone is about five to seven times more potent than morphine, according to a case series published in the Canadian Medical Association Journal.
Sarah Paquin said when her husband told her about the error, her heart sank until she realized their son hadn’t been given the medication.
“We were like, Oh my God, that was such a close call,” said Paquin. “It’s terrifying. We were very upset about it.”
David Paquin dropped his son off at school and went straight back to the pharmacy and spoke to the pharmacist, whom he described as visibly upset and apologetic.
She refunded the money paid for the wrong medication, but still couldn’t find the correct prescription. The order had to be refilled.
The owner of the pharmacy called the couple Wednesday to reassure them their son’s medication wasn’t given to anyone else, “which makes me feel a little bit better because on the flip side, I don’t want my son’s medication to hurt the wrong person either,” said Paquin.
She posted her story on a local Facebook page to warn other parents, where she learned of other complaints about the same pharmacy employee, who has been suspended pending an internal investigation.
Paquin has also filed a formal complaint with the College of Pharmacists of B.C. and was told by the college it would take about two weeks to investigate and follow up with the family.
Paquin said she regretted not double-checking the label, a mistake she said she won’t make again. She’s warning other parents to exercise the same diligence.
A West Shore couple spoke to the Times Colonist in March 2023 after a Langford pharmacy gave their son an oral suspension of sleep medication that was 14 times the prescribed dose.
Paquin said she and her husband are unnerved by the “what ifs” that replay in their minds.
“We could have given him this, sent him off to school not realizing, and he could have overdosed. He could have ended up in a coma and at the very least, probably would have had his stomach pumped.”
In a statement, Loblaw, the parent company for Shopper’s Drug Mart, called the mistake a case of “human error” that shouldn’t have happened.
The company said controls are in place to minimize the risk of patients being handed the wrong prescription, and those controls will be reviewed by employees.
The company said the pharmacy owner has reached out to the parents to apologize for any stress the incident caused and to outline corrective steps it’s taking.
