Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: MONDAY, November 14, 1994 TAG: 9411170075
SECTION: NATIONAL/INTERNATIONAL PAGE: A-1 EDITION: METRO
SOURCE: RAJIV CHANDRASEKARAN THE WASHINGTON POST
DATELINE: HAMPTON LENGTH: Long
So Mike McClave went over to the kitchen cupboard and got out a bottle of prescription medicine he had filled at a pharmacy. He mixed a couple of teaspoons into a glass of cherry-flavored 7-Up, remembering that Megan earlier had spit out the painkiller because it was bitter and "yucky."
This time she slowly sipped about half the mixture. She felt sick and drowsy, but she watched a movie on television, made Jell-O with her dad, and took a few more sips of the 7-Up mixture before crawling into bed for the night.
Megan never woke up.
Because of a horrible mistake by a Newport News pharmacist, Megan was not given the standard pain-dulling medication her doctor had prescribed but a powerful, morphine-based compound typically used to comfort terminally ill cancer patients.
McClave, four months after his daughter's death, remembers clearly the doctor's prescription: "Demerol liquid. Take two to three teaspoons every four hours for pain."
What he got instead was Roxanol, a drug at least 10 times more potent. Roxanol usually is given by the drop, not the teaspoon.
"She was just massively overdosed," said William Beaver, a professor of pharmacology at Georgetown University.
The prescription was filled July 15 at a Rite Aid pharmacy by Kent Lee Schafer, a pharmacist with more than 20 years of experience. His license was suspended indefinitely Oct. 11 by the Virginia Board of Pharmacy. The Newport News prosecutor is investigating the case.
The Pharmacy Board said Schafer dispensed the Roxanol believing it was a generic equivalent for Demerol, an error that medical experts call almost unimaginable.
"I can't even begin to understand this mistake," said Robert L. Day, associate dean of the University of California at San Francisco School of Pharmacy. "In all my years in this field, I've never heard of a case like this before."
Medical experts say that although a mistake as serious as the one that killed Megan is extremely rare, prescription errors are not as infrequent as commonly believed.
Pharmacists say their jobs are becoming tougher, and mistakes more common, because of the rapidly increasing number of medications hitting the market every year and the new generic equivalents for older drugs. Others say that an increasing workload - pharmacists who work for some large chain drugstores
and bulk prescription services that often fill hundreds of prescriptions a day - also is leading to more errors.
"It's an issue of considerable concern to pharmacy boards around the nation," said Lawrence Mokhiber, executive secretary of the New York State Board of Pharmacy.
McClave, a 38-year-old foreman for CSX railroad, told his story to the Daily Press of Newport News, which ran the first article about the case a month ago.
As he sat in a green armchair in the living room of his modest, two-level brick house in Hampton, McClave's voice choked as he recalled Megan's life.
She was supposed to begin the third grade, he said. She loved to write and draw and was in her school's gifted program. In the afternoons, she played outside, riding her bicycle up and down the sidewalk.
"It was so sudden, so tragic," he said. "There's nothing you can do as a parent to prepare or accept something like that."
The time 9:17 a.m. is indelibly etched in his memory. It was stamped on his pager when he was summoned from work July 18, the morning after Megan took her medicine, by a neighbor whom he had asked to look after Megan and her 13-year-old sister, Bethany. He had left the house while Megan was still in bed.
By the time he made it home and saw the police cars and the ambulance, he knew something was terribly wrong. The neighbor and a police officer approached him. They wouldn't let him inside to see Megan's lifeless body.
Megan's mother, Johnda McClave Thompson, drove to Hampton from her home in Baltimore later that day. She tearfully ran through the house, refusing to believe that her daughter was gone. Thompson and McClave divorced in April.
"She was such a delight. She was the love of my life," Thompson said recently, weeping over the phone. "Even now, every night I go to sleep crying for her."
It wasn't until a week after Megan's burial that her family pieced together the puzzle of her death.
Frustrated that Megan's autopsy was inconclusive, McClave's aunt, Janice Miller, 53, looked up Demerol in her American Association of Retired Persons medical guide. The book said Demerol was "pleasant-tasting, banana-flavored."
But Megan had said her medicine was bitter.
That piqued Miller's curiosity. Alone in the kitchen of McClave's house, Miller saw the bottle of medicine, put a drop on her finger and tasted it.
"It was terrible. It was the worst thing I've tasted in my whole life," Miller recalled. Then she took about a quarter-teaspoon, just to see what it would do.
After vomiting four times and feeling "sicker than I've ever been," Miller told McClave what she had done. He insisted she go to the hospital, where doctors concluded that Miller - and little Megan - had ingested the morphine compound.
McClave considers himself lucky in a strange way. At least he was able to find out how his daughter died.
"Eight-year-olds don't just die," he said. "What I want to know is how many times has this happened, and because Uncle Joe or Aunt Jane had been in their 70s, it was assumed they were just in poor health?"
A 1990 case study published by the Journal of the American Medical Association found an average of 2.5 medication errors per day at a 640-bed upstate New York hospital. A survey last year of 250 hospital pharmacists nationwide by the Pittsburgh Post-Gazette estimated there were about 16,000 medication errors in their institutions in 1992, 106 of them resulting in patient deaths.
Pharmacy experts point out that medication errors in hospitals often involve mistakes in bedside administration, which pharmacists are not involved with.
In Virginia, the Board of Pharmacy received 160 pharmacy-related complaints between November 1993 and Oct. 15, according to Scotti W. Milley, the board's executive director. Of all complaints over the last two years, about half were found to be violations.
"A lot were prescription errors, but many were things like putting the wrong name on a label," Milley said. "However, in this business you can't call anything minor."
Schafer, the pharmacist who filled Megan's prescription, will not comment on the incident. His attorney, Jeffrey R. DeCaro, who also represents Rite Aid Corp., said Schafer "very much regrets making the error." DeCaro said he would have no further comment until the Newport News commonwealth's attorney's office completes its investigation.
Although McClave isn't sure anything he could have done would have prevented Megan's death, he says what happened to his daughter should be a lesson to everyone taking prescription medications.
"Ask your doctor - ask them what's in it, what it will do, what the side effects are," he said. "Ask the same thing of your pharmacist. ... Never have blind faith."
After the article about Megan appeared in the newspaper, McClave saw a tremendous outpouring of support in this city of 130,000. His answering machine tape filled up with sympathy messages. Stacks of cards came in the mail. People would approach him in the grocery store.
Now life in his house is slowly returning to normal. He's back at work. Bethany isn't crying every night. Bethany and a couple of other children down the street decorated the house for a Halloween party.
Last year, McClave recalled, Megan dressed up as the devil. This year, he said, "she's definitely an angel."
Then he quickly got up to rummage through his desk in another room. He came back with a photo of her flower-adorned grave. He pointed to the inscription on the headstone and read it aloud, with a tear welling in his eye.
"An angel returned to heaven," he said quietly. "That's what it says."
by CNB