Case Archive
Ref. # 86338

A 74 year old Massachusetts woman with chronic lymphatic leukemia was prescribed Chlorambucil 2mg, 20 tablets to be dispensed. Directions were: four tablets by mouth daily for five days. Six refills were authorized. Forty tablets were dispensed initially, with no written directions. The patient misunderstood the directions to necessitate refills every five days, which were provided by the pharmacist. She required hospitalization three weeks later. A medQuest pharmacist reported that Chlorambucil is a carcinogenic agent that can severely suppress bone marrow function, therefore requiring extreme care in fulfilling its prescription. The initial filling of twice the prescribed amount was negligent. The prescription clearly indicated a pulse dosage to be administered at monthly intervals, as indicated in the product literature. There was a negligent failure to contact the prescribing physician regarding questions about the refill schedule, which resulted in the patient receiving an incorrect dose of a very powerful medication.

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