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Mom: Medication change potentially harmful

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Rebecca Ogle said she wouldn’t have caught a change in her daughter Abigail’s ADHD medication without the help of a nurse at W.W. Robinson Elementary School. Sally Voth/Daily


By Sally Voth -- svoth@nvdaily.com

WOODSTOCK -- W.W. Robinson kindergartner Abigail Ogle could've taken a potentially harmful dose of her medication Tuesday if it weren't for an alert school nurse.

When her daughter ran out of her attention-deficit hyperactivity disorder medicine, dextroamphetamine, Tuesday, Rebecca Ogle went to her normal pharmacy with a prescription from Abigail's pediatrician.

That pharmacy was out of the drug, so she turned to the Woodstock Wal-Mart, she said.

"I went to go pick it up and I returned it to the school, and Nurse Cary said, 'This isn't right,'" Ogle said. "She said, 'This is time-release capsules.' My daughter takes tablets."

The mom asked school nurse Cary Sigler if there was a difference between the two versions of the medicine, which Abigail takes twice a day.

"She said, 'Yeah, there's a big difference,'" Ogle recalled.

Her daughter's pediatrician's office said it hadn't written a prescription for the time-release capsules, she said, so the next call was to Wal-Mart.

"Wal-Mart said, 'It wasn't specifically written that way [for tablets], so we can fill it any way we want,'" Ogle said.

She added, "As a parent, I'm flipped out. That's scary, that's very scary. Had Nurse Cary not have caught this, we would've overdosed her."

Ogle, who also has a 3-year-old daughter, said Abigail has been taking the medicine since she was 3, but having ADHD herself, she said she knows how it feels to live with the disorder, and wanted to help her little girl.

Abigail takes 5 milligrams of her medicine at breakfast and another 5 milligrams at lunch. Both doses are given at school, and because she doesn't take it on the weekends, the pill bottle is kept at school, Ogle said. She said the doctor's office had put the name of the drug and the strength, but not what form the medicine should be in, on the prescription.

She said the manager on duty at the store Tuesday apologized to her, but said he didn't have oversight over the pharmacy.

"Stupid little people like me that trust the pharmacist," Ogle said. "As a parent, that scared the bejesus out of me. If this has happened to me, it's happened to other people and it's scary. It's terrifying."

On Wednesday, Sigler, who has worked at W.W. Robinson Elementary School for 15 years, said she was just following policy and procedure.

"We do that everyday with every child," she said. "When things don't match up, we make the phone calls."

Had Abigail taken two doses of the time-release capsules, she "absolutely" could've been harmed, Sigler said.

"As soon as we got the medicine, we caught it," she said. "Our main goal is to keep everybody safe."

A Wal-Mart manager referred any questions to the company's corporate office.

Mitsi Lizer, an associate professor of pharmacy practice at Shenandoah University, said the reason behind longer-acting capsules is so patients don't have to take a second dose midday. She said that reduces the stigma children may face if they're called to the nurse's office to take medicine.

Parents and patients should ask questions if they notice a discrepancy, Lizer said.

"I think she needs to rely on the expertise of both the pharmacist and the physician," she said. "Certainly, it's good to question. If she doesn't trust something, she should go back to the pharmacist and her physician to make sure they match up."

A Wal-Mart corporate representative couldn't be reached for comment Wednesday.




22 Comments



Dont blame the pharmacist when the prescription is written wrong. He has to follow the Dr.s instructions. And why was the school nurse the one to point out the discrepency? The mother should have been familiar with the medication.

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They change the way meds look depending on the manufacturer we should be able to trust the pharmacy to get it rite. If it's a new script they should verify what the doctor wants not make their own decision.

There's plenty of blame to go around. The doctor's office, pharmacy and parent all dropped the ball and are equally at fault. Thank goodness the school nurse did her job.

What bothers me most about this story is the drugging of children in today's society. Schools are not drug-free zones, but it's legal and there's a pill for everything. Before I would start drugging a child, I would question their diet.

Fast food consumption and over-processed meals offer little if any nutrition to a growing body. Over crowded factory-farmed animals are filled with antibiotics and growth hormones: they live under hellish conditions that no living creature should ever have to endure. This is passed on through meat and poultry. Would you like beef slime with that? It may soon be optional in our schools. Optional?!

Sugar, salt and fat are highly addictive, and is added to all of this so-called food.

Too many kids are getting a steady diet of this garbage from day one. I would have to question what this "fake food" may be doing to our children and what will be the long-term effect of these drugs?

Diana, I wholeheartedly agree, but tread lightly. Ever since NVD changed ownership, there has been a huge influx of trolling posters.

Dr. Robert Sears wrote an excellent book called "The NDD Book" that exposes the correlation between many "disorders" and early childhood nutrition. It's not that the parents are malnourishing their kids, it is the fact that you have to look hard to find good, real food.

Let the trolls feast!

For years my young son was on meds for ADHD and that in and of itself was a nightmare. It wasn't until we found out HIS daughter had so many food allergies that I went online to research the allergies and I found that many children are diagnosed with ADHD when they actually have food allergies!! Among the symptoms for food allergies were hyperness, chronic ear infections and lactose intolerance all of which my son had!! Oh if I only knew then what I know now! I would like to alert ANY parent that before they accept a diagnosis of ADHD, get the child tested for food allergies first. There is nothing to be ashamed of if your child does have ADHD, but for your child's sake and your own peace of mind, make sure the right diagnosis has been made.

No way should a pharmacist have "interpreted" a prescription and it is absolutely false to say they could fill it any way they wanted to. I have had serious medical problems all my life, and I know good pharmacists always check with doctors if there is any question on prescriptions.

"Her daughter's pediatrician's office said it hadn't written a prescription for the time-release capsules, she said, so the next call was to Wal-Mart.

"Wal-Mart said, 'It wasn't specifically written that way [for tablets], so we can fill it any way we want,'" Ogle said."

I am quoting this section for a reason. ONE,NO pharmacy should just fill it anyway they want. There is a reason that doctors write a Rx a certain way for things like this not to happen. Once that Rx leaves an office there is no way they can see if the pharmacy gives out the correct pill.

Quietwolf 56 this is also for you that the RX was written correctly it states that in the article.

Valley 3 How can you say the Dr office dropped the ball seems to me the only person who dropped it was the pharmacy.

We see news articles every day about how pharmacys have given out the wrong pill. How does a every day person who is not in the medical field know if the med isnt rx from a diffrent company. THey have to trust the pharmacy.

This is a lesson learned ask lots of questions before you leave your pharmacy if something does not look right. Check your pills.

Most pharmacy's WILL ask the person who hands them the prescription IF generics are O.K., correct? It's up to THE PERSON who picks up the prescription to MAKE SURE it is correct and alright. When you sign for these drugs, you sign where you want to (i.e. for either talking with the pharmacist or you DON'T want too).

Mother should have asked about change when she SHOULD have noticed it was different than before.

Yes the Pharmacy is at fault!!! They have records on there on every single month on how that childs script was filled. If the Walmart pharmacy would hire competent individuals to fill it's prescriptions then this might not have happened. I use to work for a pharmacy and we had to double check and recheck EVERYTHING! You do NOT assume that something is time released, if it is not written on the script TIME RELEASED then you don't do that! Plus when you pull the name up on the screen it shows everything that has been filled, how many times it has been filled, HOW it was filled. Because if their are any changes made to that prescription such as changed from taking it orally twice a day, to taking ONE time released capsule, all of that has to be entered. So yes WALMART it at fault and no one else!!!, GREAT job WW Robinson!! My children attend there and I am VERY pleased with the schools nurses!!

Except you didn't read the article. It said her pharmacy was out of the medicine so she went to Wal-Mart. How would they know what other pharmacies have done??? What pharmacy did you work for one at the CIA and they knew what all the other pharmacies in the world did? It would be nice if people would read the articles before they make comments.

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I dropped the ball...? REALLY!! I trusted the Pharmacy. Do you trust the pharmacy to give you the right meds when you drop your prescription off? meds change color and shape ALL the time. Sometimes it is because they have gotten it from a different manufacturer. How was I to know that was not the case? Ok so I didn't ask why... once again I trusted that they knew what they were doing. It was a matter of the pharmacy picking the phone up and calling the doctors office and asking is this pills or time-release capsules.

And for the comments about kids being drugged when they don't need to be, food allergies, and healthy food... I have had her tested for allergies before I put her on the meds. I did not want to "drug" my child unless that was the right thing to do. My question to you... have you ever lived with ADHD? Do you know EXACTLY how it feels to know that you have to do something (like sit in a seat for a time period, or be quiet for a time period or something as simple a sit still) and your body just will NOT let you? And healthy food... I can not afford to eat out all the time or to buy junk food. What I can afford to do is to feed my children food that will keep them strong and healthy. I like to know what I am putting in my children's bodies. Things like fruits and veggies and meats. REAL meats not pressed together stuff!

All I wanted to do was put it out there that this stuff does happen and that we as parents need to be aware of it.

Rebecca you seem like a wonderful mother.

Thank you for telling your side of the story

No one does know what is like to live with a hidden illness. Basicaly people think that it is in your head. I wish people would understand it more that it not something so easy.

As raising 2 girls and knowing it sounds like this pharmacy person was just not wanting to their 100%. I have had that before. but it is good that you have a loving and caring nurse at school.

As for Diane I understand what you are saying and I think think that the USDA needs to come up with a way to make everything healther for everyone.

TSTAR im sorry your son was miss diagnisos but is you lived a true life of ADHA and Bi polar you would understand why the meds needs right all time.

As you yourself said: All I wanted to do was put it out there that this stuff does happen and that we as parents need to be aware of it.

YOU need to be aware and responsible for what you get. You assumed and you know what that means. If you notice it's NOT THE SAME as you usually get, you ASK!

Rebecca,

I just wanted to clear up any confusion or misunderstanding of my earlier post. My comments about the food allergies vs ADHD were meant for networking information to others in similar situations. The story of my son was some 20 years ago and what they knew then was limited as compared to what they know now. I would have been grateful had someone given me the information about food allergies back then.

As far as a misdiagnosis for my son goes, we'll never know for sure because the information I found about food allergies and ADHD came way after the fact. I wanted to make sure you knew that I was not implying your child was misdiagnosed.

What I do know for sure is that dextroamphetamine is a Schedule II controlled substance that leaves NO wiggle room for a pharmacist to "fill it any way he likes" if the prescription itself wasn't clear. Shame on the pharmacist for presuming they knew best or could read the intent of the doctor's prescription while filling a small child's prescription of a Schedule II controlled substance. Downright dangerous and the pharmacist should have known better! No excuses!

In closing, nice job Cary Sigler! Whether you were just doing your job or not, it was still a job well done!

Rebecca,

I just wanted to clear up any confusion or misunderstanding of my earlier post. My comments about the food allergies vs ADHD were meant for networking information to others in similar situations. The story of my son was some 20 years ago and what they knew then was limited as compared to what they know now. I would have been grateful had someone given me the information about food allergies back then.

As far as a misdiagnosis for my son goes, we'll never know for sure because the information I found about food allergies and ADHD came way after the fact. I wanted to make sure you knew that I was not implying your child was misdiagnosed.

What I do know for sure is that dextroamphetamine is a Schedule II controlled substance that leaves NO wiggle room for a pharmacist to "fill it any way he likes" if the prescription itself wasn't clear. Shame on the pharmacist for presuming they knew best or could read the intent of the doctor's prescription while filling a small child's prescription of a Schedule II controlled substance. Downright dangerous and the pharmacist should have known better! No excuses!

In closing, nice job Cary Sigler! Whether you were just doing your job or not, it was still a job well done!

For All of you seemingly EXPERTS on here that are blaming the parent... you are absolutely wrong. First, I do agree that it is the responsibility of the Dr., the pharmacy and the parent to pay close attention to medications. HOWEVER, the newspaper article plainly said that the Drs. office did NOT write the Rx for the CR meds. Since when does ANY pharmacy have the right to "fill it anyway we want" their words not mine. And 3rd, I am one of the fortunate ones as far as taking meds. I have a great pharmacist. However, 10 years ago I took an Rx into a pharmacy for PREVACID and they gave me a Rx for PROZAC! Now, who made that mistake? NOT ME, NOT THE DR. It was the PHARMACY. And I caught the mistake ONLY because I am a Paramedic! Yes, we all make mistakes, but in the case that we are discussing it was FIRMLY the pharmacy that dropped the ball. Maybe some of you should read the statistics on just how many people DIE every year due to mistakes made by pharmacies!

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Tstar~
Thanks :) I just wanted to make sure that everyone knew that I tested and double checked before I put Abby on any meds. And as for Cary Sigler... she is a hero in my eyes!!

Ironically, all this arguing is coming about over an instance when the system worked! It's nice to know that some of the doublechecks in life function as planned. Let's all be grateful that no one was hurt and move on.

If a doctor does not specify tablet or capsule and the pharmacy stocks both, then it is acceptable to choose one or the other without having to clarify. However, if there is a difference in their time release, it is NOT ok to substitute. So for this particular situation, the substitution was not appropriate and the double-checks in place within the pharmacy failed. To err is human. We all make mistakes. It's always the hope that the mistakes never reach the patient. And thank God, the school nurse prevented any harm.

Ms. Ogle, I didn't mean to offend you or doubt your devotion as a mother. And yes, I do know something about ADHD but have not "lived with it". My comment was really meant more as a general observation about the vast number of children who are on drugs today. Why? What is going on?

Personally I really do not trust our food sources. I believe there is good reason to be concerned about what we are putting in our children's bodies. If you are not eating at the local, convenient fast-food places, you are very unique indeed and yes, I agree, it is difficult to find affordable, healthy food.

I do worry about the long-term effect of children being medicated. I do understand your frustration: you are given limited choices. Glad the nurse was on top of this.

Again I am very sorry that I sounded critical of you, and I certainly wish you the best: your comments have helped open this up for discussion and that's what we need to have on such important issues.

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There are two things that come to mind when i read the criticism of this mom. 1. No, many people do NOT have any clue what it is like to deal with an ADHD child. I am very anti-drug and went through YEARS of different parenting ideas and tricks to deal with my son, but to no avail. Finally I had him put on the drugs that I criticized myself for so many years. 2. This situation only reaffirms a very simple and well known (Although not readily admitted to) fact, that doctors, hospitals, pharmacists and LEGAL DRUGS kill more people yearly than all illegal drugs combined. Criticize Rebecca all you want, when the simple fact is, MOST of us, me included, would buy the "Usual" prescription, take it and drop it off at school without even looking at it. If this med comes in different forms, some of which can be lethal if taken wrong, THE DOCTOR SHOULD HAVE SPECIFIED ON THE PRESCRIPTION. And the fact that a Pharmacist would do something like that without checking with the dr first is flat out scary. Why don't we look at this and discuss it as what it is....Living proof of what a bunch of over-paid screw-ups plague the medical profession and risk the well being of millions.



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