Another pharmacy mishap, another young life cut short

Once again, we visit the issue of pharmacy mishaps. recently reported on the death of an 8-year old boy which the mother blames on a mistake made by a compounding pharmacy months prior. The boy, Jake Steinbrecher from Loveland, Colorado, had originally been taking clonidine in pill form. The pills were 0.1mg each and needed to be cut into fourths to achieve the required dosage of 0.025mg.

And then Jake outgrew that dosage and needed 0.03mg or about a third of a pill. From the story:

“But then he grew in size and we needed to go to a third,” Steinbrecher said. “And you can’t cut thirds so we went to compounding it.”

Jake’s new prescription called for 0.03mg doses dissolved in liquid form. They filled the prescription at Good Day Pharmacy in Loveland, Colorado, on Oct. 31.

“Within a few minutes, he fell into such a deep sleep his dad couldn’t wake him up,” Steinbrecher said. “I was pinching him and shaking him and I could not get him to open his eyes.”

They rushed Jake to the hospital where he was eventually airlifted to Children’s Hospital in Denver. He was having seizures, hallucinating and had swelling in his brain.

It turns out, that instead of a 0.03mg dose, he had gotten a 30mg dose. That was in 2015 October. Fast forward to June 7 of this year:

On June 7, Jake fell ill, and began vomiting and urinating blood. His mother rushed him to the hospital. His blood platelets were clotting throughout his bloodstream. This time, the little boy didn’t make it.

The story is still developing, but I wanted to get my thoughts on this out there. From my previous post on a similar situation (skip down to about halfway through or search for the phrase “And there are other situations similar to this”), compounding pharmacies are a favorite target of regulators. Maybe there is a sound reason to this, or maybe not. But often compounding pharmacies are the only choice for certain medications, and to be reduced simply to what CVS, Walgreens, etc are willing to mass dispense in pill form would spell disaster for a large number of patients across the country who currently depend on them.

It’s the “chilling effect” at work once again. When running a compounding pharmacy starts to be considered too much of a risk, fewer will do so, so there will be fewer in operation. Maybe this is exactly what “big pharma” wants in the long term. What the heck do they propose we do in cases like Jake’s where it’s simply impossible to cut a pill into the required dosage?

I can tell you that it’s certainly possible to get dosages wrong even at a non-compounding pharmacy. That said, a simple quick check on or a similar reference would have shown that a dosage of 30 mg was way out of whack. I am inclined to believe any decent pharmacist should have caught this error before it left the pharmacy.