Today's post comes to your courtesy of yet another of my revered Canadian colleagues: pharmacist Scott Gavura, author of the excellent Science-Based Pharmacy blog.
Back in April, 21 Venezuelan polo horses from the Lechuza team died at the U.S. Open Polo Championship in Palm Beach County, Florida after being injected with a compounded supplement similar to Biodyl®intended to prevent equine rhabdomyolysis syndrome (EMS) - known otherwise as "tieing-up" or azoturia.
Franck's Pharmacy in Ocala, Florida - the heart of Florida's equine community - was the compounding pharmacy where the supplement recipe was prepared. The cause of the horse deaths was attributed to selenium overdose.
The Orlando Sentinel and Drug Topics report that a 13-year pharmacy technician, Sheila Harris, has filed suit against the company for terminating her following her cooperation with a US Food and Drug Administration investigator. The Sentinel story reports that Harris mixed the fatal supplements and supplied the investigator with "the mixing directions she was given by the lab pharmacy manager."
The pharmacy claims Harris was terminated in a company-wide restructuring and that they encouraged all employees to cooperate with investigators. While not articulated, one might suspect that Franck's suffered some revenue challenges following the negative publicity surrounding this tragedy. Harris, however, claims retaliation.
Some commenters on our post back in April noted that Franck's Pharmacy has an excellent reputation in the equine community and that many in the veterinary medicine community continue to trust the organization.
I'm still waiting for an official report on the magnitude of the mistake in the formulation of sodium selenite in the supplement. I continue to hypothesize that it was a decimal point mistake, perhaps as bad as "micrograms" being mistaken as "milligrams."
it's interesting that these stories are always told from such a lopsided perspective. she claims she was fired for giving everything she knew to investigators, but it's equally possible that she was fired for making that mcg/mg mistake, right?
a similar case happened in a hospital in Las Vegas where a pharm tech killed a premie making the mcg/mg mistake. I guess it's not as uncommon as it should be.
Not hardly uncommon. We lost that Mars orbiter years ago because the 'rocket scientists' couldn't or forgot to convert english to metric correctly. So it goes.
My mother has been a nurse for 40 years at the same hospital, and from some of the tales she has told me of untrained nurses making rookie mistakes, I'm surprised cases like the preemie that MikeMa brings up don't happen more often.
This is also another reason why the regular practice of having nurses work 15 or so hours on the days they work is maybe not the best approach (which is what usually happens with overtime on a 12-hour day). I assume pharmacy techs would have more regular hours, but the current nursing system is a disaster waiting to happen.