A pharmacy error brings elderly woman at risk: ‘It nearly killed her'

Content Warning: This article discusses a distressing fatal incident involving medical complications, hospitalisation, and severe health consequences. Reader discretion is advised.

It's heartbreaking to think of a mistake made in a medical setting proving fatal for a loved one, especially for a loving daughter watching helplessly as her mother’s health deteriorates.

The cause of this tragic turn of events, according to her, was a pharmacy error that led to her mother overdosing on her medication, a mistake that ‘nearly killed her’.



Maria, Lisa Carratelli’s 87-year-old mother, had been prescribed methotrexate.

Methotrexate is a potent chemotherapy drug used to treat various conditions, including cancer, autoimmune diseases, ectopic pregnancies, and rheumatoid arthritis, the latter being Maria's ailment.


compressed-pexels-anna-shvets-3845126.jpeg
An 87-year-old mother overdosed on a prescribed medicine due to a pharmacy error. Credit: Pexels



However, when Maria started feeling unwell and complaining due to a persistent sore throat, she was admitted to Maroondah Hospital in Victoria.

The doctors there grew alarmed after inspecting her Webster pack, a pre-packaged medication dispenser packed by pharmacists for patients with multiple medications.

Lisa said: ‘The hospital started questioning her medication and called the pharmacist.’

‘She was supposed to take two [tablets] once a week, but the pharmacy had packed the Webster packs with two tablets daily'.

This meant Maria was consuming seven times the prescribed amount.

A discharge document from Box Hill Hospital, where Maria was later transferred, indicated that she was suffering from 'methotrexate toxicity resulting in Mucositis with Pancytopenia'—a condition characterised by low levels of red blood cells.

'It burnt all inside of her mouth and down her throat. She was in hospital for quite a long time,' Lisa continued.

'Then she ended up in rehab for months before we had to put her in a nursing home because she's not been able to recover.'



In addition to the internal burns, Maria also lost her hair, a common side effect of chemotherapy. Now, the 87-year-old is 'very fragile,' a devastated Lisa said, convinced 'the pharmacist nearly killed her'.

The pharmacist, who happened to be their family friend from a Melbourne suburb, allegedly apologised after he knew what had happened but claimed it wasn't he who had made the pack.

He allegedly sent the family 'a big bunch of flowers'—but Lisa hadn’t heard from him since.

Lisa reached out to several solicitors, hoping to pursue the case to ensure no other families suffered the same fate.

'They keep saying, because of her age, that there was nothing that they could do for us,' she said.

She also reported the incident to the Pharmacy Board of Australia but was told the same thing.



Lisa reached out to the media after learning about an Aussie mum Jessica Smith, whose toddler overdosed on his epilepsy medication after a pharmacy committed an error on the prescription.

She's now advocating for it to be mandatory for all prescriptions to be checked by two pharmacists, instead of one, before being handed out.

Currently, in Australia, it is understood that two pharmacists are not required for the dispensing of medicines. The individual pharmacist determines the use of a double-checking process for dispensing.

'I'm not after any money or anything. I just want it not to happen to someone else,' Lisa said more than a year after the incident.

'I want to help people to understand why they should always check the medication and not just trust the pharmacist.’



A spokesperson for the Australian Health Practitioner Regulation Agency said, 'When dispensing medicines, pharmacists should be guided by professional practice standards, the Pharmacy Board of Australia’s Code of Conduct and guidelines for pharmacists including:
  • Guidelines for dispensing of medicines
  • Guidelines on dose administration aid and staged supply of dispensed medicines
Lisa's dad, a pensioner, is forced to cover the cost of his wife's care.

'When you're on a pension, they don't really get a great deal [of money],' she said.

Lisa admitted that the situation ‘could have been worse', but she is thankful her mother's alive, with the fact that 'she could have died'.

'As they get older, it doesn't mean that they just get pushed aside,' she said.



While taking medications can speed up our recoveries, too much of something can be dangerous. In a previous story, a husband shared the story about his late beloved wife, who took a prescribed drug for weight loss.

The initial results turned out promising, but the following incidents turned out to be the most heartbreaking situation he would ever experience. Read more about it here.

Key Takeaways

  • Lisa Carratelli reports that her mother's health severely deteriorated due to a mistake by a pharmacist who had been providing her medication.
  • The 87-year-old was prescribed methotrexate for her rheumatoid arthritis. However, she was mistakenly given two tablets to take daily rather than weekly, resulting in a toxic overdose.
  • Lisa alleged that the pharmacist apologised to them but claimed he was not responsible for packing the medication.
  • She is campaigning for all prescriptions to be checked by two pharmacists before dispensing and urges people to double-check their medication themselves, as well.
Members, always double-check your medication and dosage when you receive it, and don't hesitate to ask questions from your GP if something doesn't seem right. Remember, it's your health on the line, and it's always better to be safe than sorry.

Have you or a loved one ever experienced a pharmacy error? Share your experiences and thoughts in the comments below.
 
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My husband takes a few different medications, and always fills his own pill containers a week ahead. Additionally, since the government introduced medications being prescribed by their generic, not brand name, he asks me what they were known as previously, so that he is aware of what he is taking. We have to be vigilant these days for our own good.
 
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Content Warning: This article discusses a distressing fatal incident involving medical complications, hospitalisation, and severe health consequences. Reader discretion is advised.

It's heartbreaking to think of a mistake made in a medical setting proving fatal for a loved one, especially for a loving daughter watching helplessly as her mother’s health deteriorates.

The cause of this tragic turn of events, according to her, was a pharmacy error that led to her mother overdosing on her medication, a mistake that ‘nearly killed her’.



Maria, Lisa Carratelli’s 87-year-old mother, had been prescribed methotrexate.

Methotrexate is a potent chemotherapy drug used to treat various conditions, including cancer, autoimmune diseases, ectopic pregnancies, and rheumatoid arthritis, the latter being Maria's ailment.


View attachment 36204
An 87-year-old mother overdosed on a prescribed medicine due to a pharmacy error. Credit: Pexels



However, when Maria started feeling unwell and complaining due to a persistent sore throat, she was admitted to Maroondah Hospital in Victoria.

The doctors there grew alarmed after inspecting her Webster pack, a pre-packaged medication dispenser packed by pharmacists for patients with multiple medications.

Lisa said: ‘The hospital started questioning her medication and called the pharmacist.’

‘She was supposed to take two [tablets] once a week, but the pharmacy had packed the Webster packs with two tablets daily'.

This meant Maria was consuming seven times the prescribed amount.

A discharge document from Box Hill Hospital, where Maria was later transferred, indicated that she was suffering from 'methotrexate toxicity resulting in Mucositis with Pancytopenia'—a condition characterised by low levels of red blood cells.

'It burnt all inside of her mouth and down her throat. She was in hospital for quite a long time,' Lisa continued.

'Then she ended up in rehab for months before we had to put her in a nursing home because she's not been able to recover.'



In addition to the internal burns, Maria also lost her hair, a common side effect of chemotherapy. Now, the 87-year-old is 'very fragile,' a devastated Lisa said, convinced 'the pharmacist nearly killed her'.

The pharmacist, who happened to be their family friend from a Melbourne suburb, allegedly apologised after he knew what had happened but claimed it wasn't he who had made the pack.

He allegedly sent the family 'a big bunch of flowers'—but Lisa hadn’t heard from him since.

Lisa reached out to several solicitors, hoping to pursue the case to ensure no other families suffered the same fate.

'They keep saying, because of her age, that there was nothing that they could do for us,' she said.

She also reported the incident to the Pharmacy Board of Australia but was told the same thing.



Lisa reached out to the media after learning about an Aussie mum Jessica Smith, whose toddler overdosed on his epilepsy medication after a pharmacy committed an error on the prescription.

She's now advocating for it to be mandatory for all prescriptions to be checked by two pharmacists, instead of one, before being handed out.

Currently, in Australia, it is understood that two pharmacists are not required for the dispensing of medicines. The individual pharmacist determines the use of a double-checking process for dispensing.

'I'm not after any money or anything. I just want it not to happen to someone else,' Lisa said more than a year after the incident.

'I want to help people to understand why they should always check the medication and not just trust the pharmacist.’



A spokesperson for the Australian Health Practitioner Regulation Agency said, 'When dispensing medicines, pharmacists should be guided by professional practice standards, the Pharmacy Board of Australia’s Code of Conduct and guidelines for pharmacists including:
  • Guidelines for dispensing of medicines
  • Guidelines on dose administration aid and staged supply of dispensed medicines
Lisa's dad, a pensioner, is forced to cover the cost of his wife's care.

'When you're on a pension, they don't really get a great deal [of money],' she said.

Lisa admitted that the situation ‘could have been worse', but she is thankful her mother's alive, with the fact that 'she could have died'.

'As they get older, it doesn't mean that they just get pushed aside,' she said.



While taking medications can speed up our recoveries, too much of something can be dangerous. In a previous story, a husband shared the story about his late beloved wife, who took a prescribed drug for weight loss.

The initial results turned out promising, but the following incidents turned out to be the most heartbreaking situation he would ever experience. Read more about it here.

Key Takeaways

  • Lisa Carratelli reports that her mother's health severely deteriorated due to a mistake by a pharmacist who had been providing her medication.
  • The 87-year-old was prescribed methotrexate for her rheumatoid arthritis. However, she was mistakenly given two tablets to take daily rather than weekly, resulting in a toxic overdose.
  • Lisa alleged that the pharmacist apologised to them but claimed he was not responsible for packing the medication.
  • She is campaigning for all prescriptions to be checked by two pharmacists before dispensing and urges people to double-check their medication themselves, as well.
Members, always double-check your medication and dosage when you receive it, and don't hesitate to ask questions from your GP if something doesn't seem right. Remember, it's your health on the line, and it's always better to be safe than sorry.

Have you or a loved one ever experienced a pharmacy error? Share your experiences and thoughts in the comments below.
I can remember when our boss asked his secretary to collect his script from the pharmacy and we had a good laugh over the directions the pharmacist had written. They were really sleeping pills but the pharmacist had written "take one three times per day" When checking with the pharmacist about this we were told that these were the instructions written by the doctor on the original script!! I swould hazv e thought the pharmacist would have checked with the doctor before putting "three times per day" on the directions.
 
A number of years ago a Pharmacist wrongly gave me blood pressure medication which was double the prescribed amount. I should have realised the colour of the pill was different, but trusted the national brand pharmacy. The pill nearly knocked me off my feet during the day, and luckily I checked once home. I made a complaint to the head Pharmacist, but all I got was an ‘oops sorry’. The same errant Pharmacist did the same thing months later! Should have sued them. 😳
 
In the 20 years of working in the disability sector and administering tens of thousands of individual medications in this time, this occurrence is more common than you think. A 17 year old assistant usually packs the Webster packs, not a registered pharmacist themselves.

I am currently on nine different medications and I pack my own into a Dosette box on a weekly basis. A pain in the arse but at least I know it's correct. The only problem is dropping one of the little buggers and they ALWAYS roll under some furniture!
I am currently on nine different medications and I pack my own into a Dosette box on a weekly basis. A pain in the arse but at least I know it's correct. The only problem is dropping one of the little buggers and they ALWAYS roll under some furniture! After getting some drug pusher cock pills up, like you I prefer to mine weekly.
 
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I am currently on nine different medications and I pack my own into a Dosette box on a weekly basis. A pain in the arse but at least I know it's correct. The only problem is dropping one of the little buggers and they ALWAYS roll under some furniture! After getting some pusher cock pills up, like you I prefer to mine weekly.
In the good old days, I preferred at least once a day. But we are looking back to the late 1970s now. Those were the days my friend!
 
A number of years ago a Pharmacist wrongly gave me blood pressure medication which was double the prescribed amount. I should have realised the colour of the pill was different, but trusted the national brand pharmacy. The pill nearly knocked me off my feet during the day, and luckily I checked once home. I made a complaint to the head Pharmacist, but all I got was an ‘oops sorry’. The same errant Pharmacist did the same thing months later! Should have sued them. 😳
When I got tablets in the wrong amount I made sure I didn't take the different amount without checking with my doctor, after all, he was the one who prescribed the tablets in the first place and had a record of what I should be taking.
 
Content Warning: This article discusses a distressing fatal incident involving medical complications, hospitalisation, and severe health consequences. Reader discretion is advised.

It's heartbreaking to think of a mistake made in a medical setting proving fatal for a loved one, especially for a loving daughter watching helplessly as her mother’s health deteriorates.

The cause of this tragic turn of events, according to her, was a pharmacy error that led to her mother overdosing on her medication, a mistake that ‘nearly killed her’.



Maria, Lisa Carratelli’s 87-year-old mother, had been prescribed methotrexate.

Methotrexate is a potent chemotherapy drug used to treat various conditions, including cancer, autoimmune diseases, ectopic pregnancies, and rheumatoid arthritis, the latter being Maria's ailment.


View attachment 36204
An 87-year-old mother overdosed on a prescribed medicine due to a pharmacy error. Credit: Pexels



However, when Maria started feeling unwell and complaining due to a persistent sore throat, she was admitted to Maroondah Hospital in Victoria.

The doctors there grew alarmed after inspecting her Webster pack, a pre-packaged medication dispenser packed by pharmacists for patients with multiple medications.

Lisa said: ‘The hospital started questioning her medication and called the pharmacist.’

‘She was supposed to take two [tablets] once a week, but the pharmacy had packed the Webster packs with two tablets daily'.

This meant Maria was consuming seven times the prescribed amount.

A discharge document from Box Hill Hospital, where Maria was later transferred, indicated that she was suffering from 'methotrexate toxicity resulting in Mucositis with Pancytopenia'—a condition characterised by low levels of red blood cells.

'It burnt all inside of her mouth and down her throat. She was in hospital for quite a long time,' Lisa continued.

'Then she ended up in rehab for months before we had to put her in a nursing home because she's not been able to recover.'



In addition to the internal burns, Maria also lost her hair, a common side effect of chemotherapy. Now, the 87-year-old is 'very fragile,' a devastated Lisa said, convinced 'the pharmacist nearly killed her'.

The pharmacist, who happened to be their family friend from a Melbourne suburb, allegedly apologised after he knew what had happened but claimed it wasn't he who had made the pack.

He allegedly sent the family 'a big bunch of flowers'—but Lisa hadn’t heard from him since.

Lisa reached out to several solicitors, hoping to pursue the case to ensure no other families suffered the same fate.

'They keep saying, because of her age, that there was nothing that they could do for us,' she said.

She also reported the incident to the Pharmacy Board of Australia but was told the same thing.



Lisa reached out to the media after learning about an Aussie mum Jessica Smith, whose toddler overdosed on his epilepsy medication after a pharmacy committed an error on the prescription.

She's now advocating for it to be mandatory for all prescriptions to be checked by two pharmacists, instead of one, before being handed out.

Currently, in Australia, it is understood that two pharmacists are not required for the dispensing of medicines. The individual pharmacist determines the use of a double-checking process for dispensing.

'I'm not after any money or anything. I just want it not to happen to someone else,' Lisa said more than a year after the incident.

'I want to help people to understand why they should always check the medication and not just trust the pharmacist.’



A spokesperson for the Australian Health Practitioner Regulation Agency said, 'When dispensing medicines, pharmacists should be guided by professional practice standards, the Pharmacy Board of Australia’s Code of Conduct and guidelines for pharmacists including:
  • Guidelines for dispensing of medicines
  • Guidelines on dose administration aid and staged supply of dispensed medicines
Lisa's dad, a pensioner, is forced to cover the cost of his wife's care.

'When you're on a pension, they don't really get a great deal [of money],' she said.

Lisa admitted that the situation ‘could have been worse', but she is thankful her mother's alive, with the fact that 'she could have died'.

'As they get older, it doesn't mean that they just get pushed aside,' she said.



While taking medications can speed up our recoveries, too much of something can be dangerous. In a previous story, a husband shared the story about his late beloved wife, who took a prescribed drug for weight loss.

The initial results turned out promising, but the following incidents turned out to be the most heartbreaking situation he would ever experience. Read more about it here.

Key Takeaways

  • Lisa Carratelli reports that her mother's health severely deteriorated due to a mistake by a pharmacist who had been providing her medication.
  • The 87-year-old was prescribed methotrexate for her rheumatoid arthritis. However, she was mistakenly given two tablets to take daily rather than weekly, resulting in a toxic overdose.
  • Lisa alleged that the pharmacist apologised to them but claimed he was not responsible for packing the medication.
  • She is campaigning for all prescriptions to be checked by two pharmacists before dispensing and urges people to double-check their medication themselves, as well.
Members, always double-check your medication and dosage when you receive it, and don't hesitate to ask questions from your GP if something doesn't seem right. Remember, it's your health on the line, and it's always better to be safe than sorry.

Have you or a loved one ever experienced a pharmacy error? Share your experiences and thoughts in the comments below.
This is a disgrace! The fact that it's NOT a sue-able offence because of her age? That's decidedly ageist! It's a total disgrace that anyone should get away with anything harming someone...it's basically saying, " we allow accidental murder, because they're too old and we don't care!!
 

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