She picked up her kid's ADHD medication, but was given an opioid instead

A fuss on george vancouver Island is warning people to duplicate check out their prescriptions after she was accidentally dispensed the powerful opioid hydromorphone instead of her son's fixture ADHD medication. 

Comox, B.C., resident Sarah Paquin, 31, says she still shudders to think about what could have happened to her nine-year-old son had her husband not noticed the medication looked different before he gave it to him. 

"It was terrifying," Paquin said, standing in her front yard and playing with one of her three boys. 

"One simple little mistake like that could have ended horribly."

Pharmacy mix-up leaves child with hydromorphone pills

Paquin says she didn't think too much of it when she went to pick up her son Declan's medication last week and the staff member at her local Shoppers Drug Mart pharmacy didn't check her ID or take out the prescription from the bag. 

The next day, her husband was about to give Declan his medication when he saw the pills were a different colour and shape than normal. 

Her husband looked at the bottle and noticed the prescription was for someone else, and that it was for five milligrams of hydromorphone. Right away he returned the pills to the pharmacy. 

"Immediately your mind goes to the worst case scenario," Paquin said. 

"The results could have been catastrophic and it just makes my heart sink to think about what could have happened."

Hydromorphone is a powerful opioid that is two to eight times stronger than morphine and is often used to treat acute pain or chronic cancer pain. 

According to the Mayo Clinic, it can cause serious unwanted effects or fatal overdose in children. 

In a written statement, the company said the incident was a case of "human error" that never should have happened.

"We have controls in place to minimize risks like this — where the patient was handed the wrong prescription bag — and the associate will review these with employees to avoid a similar situation in the future," the company said. 

Paquin says she has since heard from the pharmacist, who was very apologetic. She says he acknowledged that steps were missed and standards were dropped, and told her the employee who dispensed the medication has been suspended pending an internal investigation. 

Despite his reassurances, Paquin has filed a complaint with the College of Pharmacists of B.C.

"The pharmacy needs to take responsibility, be held accountable for what happened," she said. 

"We have legal requirements in the Health Professions Act bylaws in place to prevent these occurrences, including mandatory standards for prescription preparation to ensure accuracy of the prescription product and consultations for all prescriptions, to make sure clients understand their medication, how to take it properly, and address any questions," the college said. 

As part of pharmacists' consultation with clients, they are required to confirm the person's identity, name and the strength and purpose of the drug, it added. 

In 2023-24, the college says it received a total of 990 concerns through its intake process. Of those, 54 became formal complaints and investigations, 16 of which were medication related. 

Paquin decided to share her ordeal on social media, to warn others to check their prescription before taking it. 

"It's scary that it happened to us, but I'm also in a way kind of thankful that it happened to us and we caught it because it could have been given to somebody who didn't notice and got hurt," she said. 

@MaryseZeidler

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