The Label on the Pill Bottle

Terry Paul Smith, a 46-year-old roofer, suffered from a disorder of the peripheral nerves (neuropathy) in his back and legs, which kept him in chronic pain. He took Oxycontin and Neurontin, but he disliked the way it made him feel, e.g., making him sometimes "drop out" in the middle of a conversation. After he complained about the pain medications' side effects, his doctor changed the prescription to methadone. The doctor wrote a prescription for Terry to take four 10-milligram pills, twice a day. Terry filled the prescription at a local Walgreen's pharmacy in Jacksonville, Florida. The label on the pill bottle directed Terry to take four tablets "as needed for chronic pain," and did not mention any limits on the frequency. Terry took the pills for the first time on July 23-24, 2001. Within 36 hours, Terry was dead. The autopsy found toxic levels of methadone in his blood. The pharmacist's error to "take as needed" rather than take "twice a day" increased the risk of Terry's death. Now Terry's widow, Pearl Smith, is pursuing a lawsuit against Walgreen's. A company spokesman says Walgreen's has spent $1 billion over the last decade on pharmacy safety systems, safety training and technology. Walgreen's filled more than half a billion prescriptions in the last fiscal year.

This overdose death illustrates the importance to discuss the doctor's prescribing orders with her and check her prescription carefully against the label on the bottle, especially for a new medicine. Read an informed consent story, or read more from the source article by Kevin McCoy in the USA Today of Nov. 2.