Caroline Steinbrecher and Tony Lynch were skeptical when their son’s pediatrician recommended a drug called Clonidine to treat the 4-year-old’s sensory processing disorder. Jake suffered from a neurological condition that made ordinary situations seem impossibly noisy and loud. Pediatricians have found success in using Clonidine to treat neurological disorders, and have prescribed the anti-hypertensive more and more often in recent years.
The concerned parents wrestled with the decision for over a year; Clonidine can be very effective, but even small doses can be toxic in young children. Eventually, they agreed that the potential benefits outweighed the risks, and Jake was prescribed a low dose of the drug. For the next three years, Jake took 1/3 of a tiny 0.1mg pill every day without incident. Last year, his parents decided to fill the prescription at a compounding pharmacy and have the drug mixed up as a liquid to make dosing easier.
Inside Edition reported, “The first bottle of liquid Clonidine that Jake took worked perfectly, but the first dosage from a second bottle of the syrup would end up killing her son, his mother said. ‘Jake complained that the medicine tasted bad,’ Steinbrecher wrote in a letter sent to the Colorado State Board of Pharmacy. ‘Within 30 minutes of receiving the medication, Jake complained of feeling dizzy and fell asleep. His father called me very scared and said something was wrong with his medication.’”
The mistake of a lifetime
Something was very wrong with Jake’s prescription; a pharmacy error meant that instead of his normal .03-milligram dose, Jake was given 1,000 times that amount. The massive overdose became quickly apparent. For the next few weeks, Jake underwent a battery of tests from the pediatric intensive care unit. His condition deteriorated, and CAT scans showed evidence of traumatic brain injury and brain swelling. Always a fighter, Jake showed signs of improvement and was released from the hospital in November 2015 after a three-week stay, though his health would never be the same. On June 8 of this year, Jake died suddenly from “an autoimmune response believed to have been triggered by the error.”
The Inside Edition Special Report referred to Jake’s overdose as a sentinel event; since his death, others have come forward with similar stories involving Clonidine. These numbers from Medscape give a better picture, “Of the 5063 reported toxic exposures to clonidine in 2014, 1769 were in patients younger than 6 years, 1965 were in patients 6-19 years old, and 1239 were in patients 20 years of age and older.” More than 70% of toxic exposures affected children under the age of 19.
Jake Steinbrecher’s death was the result of an avoidable medical error. There is no system that tracks pharmaceutical errors like this one, and the pharmacist who made the error has faced no consequences of any kind. The matter has been referred to the State Board of Pharmacy, which is investigating the “incident.” For Carolyn Steinbrecher, that’s not good enough. She told Inside Edition, “I’m petrified I’m going to flip on the news on day and I’m going to hear about another child dying from a compounding error and I just can’t have that happen.”
Talk to your doctor about dangerous drugs
Pharmacy errors are more common than we like to believe. With dangerous drugs, sometimes a less effective but safer alternative is a better option. While Clonidine is particularly devastating, all drugs have the potential to be life threatening when the wrong dose is given at the wrong time. Patients can check documentation and confirm instructions, research medications and understand conditions, but care is ultimately in the hands of professional pharmacists and other healthcare providers.
If your loved one has suffered from a medication error, you may be entitled to compensation. The compassionate and experienced Nashville dangerous drug attorneys at Rocky McElhaney Law Firm can evaluate your case and help get you the compensation you deserve. Call 615.246.5549, visit our offices in Nashville, Gallatin, or Knoxville, or contact us today for a free consultation.
