THE VIRGINIAN-PILOT
Copyright (c) 1994, Landmark Communications, Inc.
DATE: Monday, October 31, 1994 TAG: 9410310070
SECTION: LOCAL PAGE: B5 EDITION: FINAL
SOURCE: ASSOCIATED PRESS
DATELINE: HAMPTON LENGTH: Long : 109 lines
Two days after getting her tonsils out, 8-year-old Megan Colleen McClave told her father in a raspy voice that her throat was aching.
So Mike McClave went over to the kitchen cupboard and got out a bottle of prescription medicine he had filled at a local pharmacy. He mixed a couple of teaspoons into a glass of cherry-flavored 7-Up, remembering that Megan earlier had spit out the pain killer 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.
The next morning, 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, 3 1/2 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 is usually 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 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 is commonly believed.
Pharmacists say their jobs are becoming tougher, and mistakes more common, because of the rapidly increasing number of medications on the market every year and the new generic equivalents for older drugs. Others say that an increasing workload - pharmacists who work for some chain drug stores and bulk prescription services often fill hundreds of prescriptions a day - 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 Newport News Daily Press, which ran the first article about the case two weeks ago.
Last week, sitting 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 this year, he said. She loved to write and draw and was in her school's gifted program. In the afternoons, she always 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 still there, 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 last week. ``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.
Miller found the bottle of medicine in McClave's kitchen, 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.
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 of 250 hospital pharmacists nationwide conducted last year 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.
Medication errors in hospitals often involve mistakes in bedside administration, which pharmacists are not involved with.
Schafer, the pharmacist who filled Megan's prescription, has refused to comment on the incident. by CNB