Pharmacists' failure to check drug risks leads to 'horrible' death

A B.C. man is going public to warn others after his mother was killed by an adverse interaction between two prescription drugs, a well-known risk that was overlooked by health professionals she trusted.

"There was a physician and two pharmacists and a computer system that all failed here. It’s not a simple mistake,” said Ernie Lambert, whose mother died in 2012.

Helena Lambert's local pharmacists dispensed the medications without noting or warning of the potential problems of taking them concurrently, even though widely used software at the pharmacy would have flagged the potential adverse interaction. 

"The procedures weren’t followed. What [electronic] warnings there were, were ignored," Ernie Lambert said.

"She wasn’t going anywhere without a fight. The problem is, this wasn’t a fair fight. She didn’t have a hope."

Helena Lambert, from Creston, B.C., was 76, and healthy and active for her age, when she was prescribed allopurinol to treat her gout. She was already on mercaptopurine, an immunosuppressant, for colitis.

Six weeks after starting her new medication — just home from a holiday with her children and grandchildren — she developed a blister on her foot.

Ernie Lambert took his mom to the Creston Valley Hospital, where doctors determined the interaction between the two drugs was causing her immune system to shut down.

"The doctors there figured out very quickly what had gone wrong," Lambert said. "They were as appalled by this as I was, because of these two drugs and how well known the interaction between them is."

The doctors determined the blister was caused by a bacterial infection that spread quickly. 

He said his mom suffered terribly, before dying from infection and respiratory failure.

"She was so frustrated and so angry," Lambert said, in tears. "It was a terrible struggle. It was a horrible way for anybody to die."

Lambert pushed for an investigation, and a B.C. coroner confirmed the drug interaction caused his mom’s death. He then filed complaints with regulators against the pharmacist and her doctor.

'Alert fatigue' revealed

Evidence submitted by the doctor, Kriegler Le Roux, suggested the death was a worst-case scenario, triggered by a growing phenomenon among pharmacists called "alert fatigue."

That's when pharmacists ignore or turn off the flags in their computer systems — the ones that alert them to drug interaction risks — because they are overloaded by too many warnings, from mild to severe.

Le Roux, who prescribed both medications, told his regulator he relies on pharmacists to check whether there are known drug-interaction issues. He believes that in this case, the pharmacists didn’t even see the warnings in the system used at the Creston Pharmasave.

"The community pharmacist informed me that because there are so many potential interactions between medications, they have to tune down their [software] system not to flag less common or troublesome interactions," the doctor wrote to the College of Physicians and Surgeons of B.C.

"We need a better flagging system," Le Roux told Go Public.

He was criticized by his regulator for not adjusting Lambert’s drug dosages to reduce the risk when he prescribed the second drug.

Le Roux was required to take a one-day course because of the mistake he made.

"I definitely pay more attention to this now — and I tell my friends."

The pharmacists involved were each suspended for 30 days by the College of Pharmacists of B.C.

Pharmacists didn't heed flags

It concluded that Mike Ramaradhya, who filled the initial allopurinol prescription, and James Hill, who refilled it, didn’t heed information in Pharmanet, the database accessible by all B.C. pharmacists. The pharmacy also uses other software that would have flagged the interaction. 

The college said the drug interaction risk between allopurinol and mercaptopurine is pegged at Level 2, which is mid-range.

"These alerts should serve as the triggering point for a pharmacist to conduct a thorough assessment of the issue being flagged.... There is no good excuse for overlooking any … drug interaction," the college said in its findings.

"It was clear to the committee that both Mr. Ramaradhya and Mr. Hill neglected their duties."

The Creston Pharmasave, where the drugs were dispensed, refused to say anything about this case.

"All members of staff and management at Pharmasave 282 in Creston are not able to provide you with any comments, written or verbal, relating to specific patients," it said in an email.

Go Public then asked if the pharmacy has changed any of its general practices because of Lambert’s death, but received no reply.

Widespread concerns

"The whole issue of alert fatigue is one that we are really struggling with. It is information overload," said Julie Greenall, a pharmacist with the Institute for Safe Medication Practices Canada.

"Other people can learn from this."

She said various software programs rate the same drug interactions differently, which can make alerts ambiguous or confusing.

"They are not always easy to interpret. There are probably numerous times I have missed information that could have been clinically significant," Greenall said.

"The risk of clicking through" — and not reading electronic alerts about a possibly harmful mixing of medications — "could vary from nothing to a severe situation depending on the drugs involved and the particular patient."

Calls for system restrictions

Greenall said her institute wants systems redesigned to force pharmacists to enter a reason before overriding an alert.

"A better system that the pharmacy or the pharmacist can’t tinker with would probably be the right solution," agreed University of Victoria drug policy researcher Alan Cassels.

"When you are in a retail setting, the pharmacist is probably harried, is under pressure to deliver and yet doesn’t have time to do the proper counselling and to see the alerts properly."

He pointed out that drug interaction problems are very common, particularly in the elderly, and sometimes aren’t even detected as a cause of illness.

"One death is really the tip of the iceberg. I think there are many hundreds, probably thousands of adverse drug reactions that happen." 

The pharmacists’ regulator indicated it is increasingly concerned about alert fatigue. The College of Pharmacists said it will be warning members in upcoming practice reviews that all prescriptions must be checked for risks, big or small.

"And if it’s a constant problem — if it’s something where they have created systems to circumvent actually checking the profiles — those will get punted to our inquiry committee," deputy registrar Suzanne Solven said.

Ramaradyha still works at the Pharmasave. Hill left his job there in the spring. Lambert can’t understand why they didn’t lose their licences.

"Fatigue and overload — I understand that. But it's not an acceptable excuse to not do what you need to do," he said. 

'People need to know'

 "I can’t believe how lackadaisical and how accepting [regulators] are that this occurred. Nobody seems to give a damn."

"Any dispensing error is serious and the committee looks at that. But taking away somebody’s licence is a very serious action," Solven said. "It’s somebody’s livelihood."

Lambert hopes after hearing his mom’s story, other patients will beware.

"People need to know," he said. "People need to ask questions. You know, question your doctor. Question your pharmacist."

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