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Lawsuit alleges fatal chemo drug error by community pharmacist

A lawsuit has been filed alleging that a New Jersey community pharmacist dispensed a gross overdose of a chemotherapy drug that resulted in the death of a 23-year-old woman with brain cancer.

Ximena Clavijo's prescription for lomustine (CeeNu, Bristol-Myers Squibb Oncology) called for a total dose of 190 mg to be taken once every six weeks, according to the lawsuit filed in state Superior Court by her family against the pharmacist and Abel's Pharmacy in Paterson. The suit charges that the prescription called for one 100-mg capsule, two 40-mg capsules, and one 10-mg capsule. However, the Rx label attached to each 20-capsule box indicated the dose was to be taken every day. Since a total of 40 doses for each strength was dispensed, the woman received five years of therapy, said Eric Smith, the family's attorney.

The woman, a Notre Dame graduate who planned to pursue an advanced social work degree, began taking the drug last Feb. 20 and continued until March 16 when she became so ill, she was rushed to a nearby emergency room, where the overdose was discovered, Smith said. She consumed a combined dosage of more than 4,700 mg of lomustine, for which there is no antidote. She died on April 20 of multiple organ failure stemming from sepsis directly related to the overdose, he added.

"The pharmacist says he questioned the script and called the doctor, who told him the intention was one dose a day for 42 days," Smith said. "My opinion is that he's not going to be believed because no doctor who knows anything about this drug or oncology would give such a large dose. This is the largest dose ever recorded and, of course, it killed her."

Due to legal constraints, the pharmacist declined to comment on the suit. "I'd like to help, but I really can't talk about it," he told Drug Topics.

When the Rx was dispensed, the family was given a computer-generated information sheet in Spanish, Smith said. The sheet stated that the drug was to be given once very six weeks, which contradicted the Rx labels. He declined to say whether the family had read the printed Rx information sheet. He added that the Clavijo family, which had emigrated from Ecuador in 1984, has no problems with English, and a language barrier did not factor into the error.

"There was nothing illegible about the prescription," Smith added. "I could read it, and I'm not a doctor. It has a backward "q," which indicates every six weeks. My impression, without any facts, is that the clerk handled the script, not the pharmacist. Maybe I'm wrong, but I find it hard to believe a pharmacist could make such a gross mistake. We'll know a lot more about what happened after a board of pharmacy division of consumer affairs completes a comprehensive investigation to which we are not privy."

The N.J. Division of Consumer Affairs, which is attached to the Office of Attorney General, can neither confirm nor deny whether an investigation of the Clavijo incident or the R.Ph. is under way, said spokeswoman Genene Morris. She added that there were no prior disciplinary actions against the pharmacist. The executive director of the state pharmacy board could not be reached for comment.

Carol Ukens

 

Carol Ukens. Lawsuit alleges fatal chemo drug error by community pharmacist. Drug Topics 2001;1:10.