Medical error rant

[skeptigirl]

Sadly a young man just died up at Western WA University of MRSA pneumonia (http://www.king5.com/localnews/stories/NW_022108WAB_wwu_mrsa_death_TP.15c8de4c.html). That is not the error I am ranting about but there are implications involved.

A few weeks back my son got an antibiotic for acne, Doxycycline, at the university's student health clinic. He said it didn't seem to be working and he had actually gotten worse. But he said they warned him to expect that and to keep using it.

This made no sense to me. Those instructions would be accurate for Accutane (isotretinoin) where a "flare" is experienced after starting treatment. But I've never heard of it applying to starting antibiotics. I don't treat any patients currently for acne and I always keep in mind someone with current information may know something I don't but still, I was pretty sure I was right. So I told him to go back and tell them what I said.

Kid's and Mom's relationships being what they are, he declined to do so and decided to wait for the next appointment in 6 weeks like they had told him. Oh well, it's his decision and this is not one of those arguments that is worth the fight.

Then Wed, the 20th, the student at the university died of MRSA pneumonia so I emailed my son about it, asking if he knew him and giving my Mom admonition to be careful at the school gym, and so on. My son already knows this of course, but I'm a Mom.

Then today he calls me. He went to take one of the antibiotics and they were clumped together in the bottom of the bottle. He looked closer at the label and found they had expired in 2002!!!! These were dispensed to him from the student health service. THEY EXPIRED 6 YEARS AGO!!!!!!

I am livid. A few months expired, it happens. A year, maybe. But expired 6 years ago and capsules clumped together in the bottom and not working!!!. This is unacceptable.

Think about it. What if my son had MRSA and they gave him antibiotics that should have been trashed 6 years ago? How many other kids got drugs that were no good? What if the kid who died had gone to the student health service earlier in the week? A delay in getting effective treatment could have been the actual cause of death. And what other ineffective drugs have they dispensed from the student health office?

I encouraged my son to take it to the school paper. He is not the activist I am so I doubt he will. But I am going to bring it up with our doctor here. We have an HMO so they are responsible for a contract with the student health at the university.

I'm going to contact the employee health nurse at the hospital and ask her to review the chart of the young man who died and see if he was seen at the student health service. If he was this expired antibiotic needs to be brought to someone's attention.

[DanishDynamite]

Do the American thing and sue them for a Billion dollars.

Seriously, that is unacceptable.

[technoextreme]

There is a problem with your argument. From my research on a similar disease for treatment it seems like it's hyper regulated. The medication may be given out by a doctor.

[drkitten]

Do the American thing and sue them for a Billion dollars.

Seriously, that is unacceptable.

But all too common.

The basic problem is that the doctors are incompetent.

In general, doctors at university clinics are the modern equivalent of the navy surgeons who fled the country rather than face a malpractice suit. The pay and working conditions are sufficiently bad (and the prospects for professional advancement are nonexistent) that only the desperate will consider such a job.

[skeptigirl]

There is a problem with your argument. From my research on a similar disease for treatment it seems like it's hyper regulated. The medication may be given out by a doctor.What are you talking about?

[skeptigirl]

But all too common.

The basic problem is that the doctors are incompetent.

....In this case, first the prescriber typically dispenses the medication and is ultimately responsible. Regardless, anyone who actually put his name on the bottle and handed it to him or got it ready to hand out should have checked the drug name and the expiration date. That is common sense. Then the clinic staff are also responsible and there should be adequate procedures in place to pull expired drugs.

This is one of those errors that any number of people should have prevented and didn't. They are all responsible.

[skeptigirl]

...
In general, doctors at university clinics are the modern equivalent of the navy surgeons who fled the country rather than face a malpractice suit. The pay and working conditions are sufficiently bad (and the prospects for professional advancement are nonexistent) that only the desperate will consider such a job.That's not true. Some of my colleagues work at the university health center at the U of WA in Seattle and I did clinical rotations there. The working conditions are great and the pay is standard. You get free tuition and stay in the university milieu. It's a good job.

[drkitten]

This is one of those errors that any number of people should have prevented and didn't. They are all responsible.

Yes. The reason is that almost all (US) university student health clinics are festering masses of incompetents who are almost universally one complaint away from having their medical licences pulled.

This applies to the staff physicians. This applies to the staff pharmacists. This applies to the staff nurses. This would apply to the guy that vacuums the rug if there were a licensure requirement for vacuuming.

But the alternative is to have no pill-rollers at all, because doctors who can get jobs at real hospitals won't touch the student death clinics with a barge pole.

(At the graduate school I attended, every physician except one had had their license suspended for disciplinary reasons at some point prior to starting at the clinic. At my undergraduate school -- which had a medical school attached --- it was even worse. A number of the medical staff were actually unlicensed, and were "practicing" ostensibly under the supervision of the medical faculty.)

[DanishDynamite]

In this case, first the prescriber typically dispenses the medication and is ultimately responsible. Regardless, anyone who actually put his name on the bottle and handed it to him or got it ready to hand out should have checked the drug name and the expiration date. That is common sense. Then the clinic staff are also responsible and there should be adequate procedures in place to pull expired drugs.

This is one of those errors that any number of people should have prevented and didn't. They are all responsible.
It is quite possible that they are all responsible. And good luck in making whatever case you intend to make. But shouldn't this thread be in Politics, Current Events or possibly Forum Community?

It certainly has little to do in Science.

[~enigma~]

Yes. The reason is that almost all (US) university student health clinics are festering masses of incompetents who are almost universally one complaint away from having their medical licences pulled.

This applies to the staff physicians. This applies to the staff pharmacists. This applies to the staff nurses. This would apply to the guy that vacuums the rug if there were a licensure requirement for vacuuming.

But the alternative is to have no pill-rollers at all, because doctors who can get jobs at real hospitals won't touch the student death clinics with a barge pole.
Aren't you assuming that no licensed doctor, pharmacist or nurse wants to work in a university clinic?

[skeptigirl]

Do the American thing and sue them for a Billion dollars.

Seriously, that is unacceptable.No harm, no sue. If my son had been seen there, given an expired drug and had a consequence from it, then suing for damages if the case isn't settled out of court is a patient's recourse for being harmed by such a blatant error.

This is a clinic in a university dispensing an antibiotic that was 6 years!!! past its expiration date where a student died this very week from an infection that was either not treatable or not treated in time. The latter is more likely but I have no idea if he was seen at this clinic or what the circumstances were for the treatment failure. Sometimes people just wait too long to be seen. Or they are seen early on, and then are reluctant to go back too soon when they get worse.

But in one scenario, he could have been given an ineffective drug that delayed his getting treatment in time.

[skeptigirl]

Yes. The reason is that almost all (US) university student health clinics are festering masses of incompetents who are almost universally one complaint away from having their medical licences pulled.

This applies to the staff physicians. This applies to the staff pharmacists. This applies to the staff nurses. This would apply to the guy that vacuums the rug if there were a licensure requirement for vacuuming.

But the alternative is to have no pill-rollers at all, because doctors who can get jobs at real hospitals won't touch the student death clinics with a barge pole.

(At the graduate school I attended, every physician except one had had their license suspended for disciplinary reasons at some point prior to starting at the clinic. At my undergraduate school -- which had a medical school attached --- it was even worse. A number of the medical staff were actually unlicensed, and were "practicing" ostensibly under the supervision of the medical faculty.)I'm afraid your sample size of one is not representative of the universities I am familiar with.

[skeptigirl]

It is quite possible that they are all responsible. And good luck in making whatever case you intend to make. But shouldn't this thread be in Politics, Current Events or possibly Forum Community?

It certainly has little to do in Science.Is this not the Science, Mathematics, Medicine, and Technology forum?

I don't intend to make any case. I intend to get an unacceptable condition that led to the error corrected.

[drkitten]

I'm afraid your sample size of one is not representative of the universities I am familiar with.

Of two, thank you. (My graduate and undergraduate schools weren't even in the same time zone.) The actual sample size is more like seven.... and I'm afraid that I have NEVER met a competent physician, pharmacist, or nurse at a university clinic.

[DanishDynamite]

Is this not the Science, Mathematics, Medicine, and Technology forum?Yes, it is. It is not a forum for discussing legal grievances.
I don't intend to make any case. I intend to get an unacceptable condition that led to the error corrected.
And good luck to you. You have a good case as far as I can see.

But your case is hardly relevant to this forum.

[drkitten]

Yes, it is. It is not a forum for discussing legal grievances.


You're the one who brought up "legal." There's also the medical procedures question. What went wrong, what should have been done, what should be done differently to make sure that this kind of mistake doesn't get repeated in a situation where the consequence is more serious?

[DanishDynamite]

Of two, thank you. (My graduate and undergraduate schools weren't even in the same time zone.) The actual sample size is more like seven.... and I'm afraid that I have NEVER met a competent physician, pharmacist, or nurse at a university clinic.
It is interesting that some countries have doctors/clinics associated with universities. This isn't the case in my country.

Perhaps it is only of relevance when Universities become really, really big?

[DanishDynamite]

You're the one who brought up "legal." There's also the medical procedures question. What went wrong, what should have been done, what should be done differently to make sure that this kind of mistake doesn't get repeated in a situation where the consequence is more serious?
Yes, those are interesting questions. But they are not Science or Medicine questions. They are questions more suited for Social science or Politics.

[fuelair]

Sometimes, mileages vary for where things are discussed - and sometimes you need to make the choice to take one where more people who may gain from it will see it!!!

[DanishDynamite]

Sometimes, mileages vary for where things are discussed - and sometimes you need to make the choice to take one where more people who may gain from it will see it!!!
A good argument for placing this thread in Forum Community.

[Hydrogen Cyanide]

I'm afraid your sample size of one is not representative of the universities I am familiar with.

Actually several years ago I knew a doctor who worked at Hall Health Center (university medical clinic named for a person whose last name was "Hall"). She was a real doctor who was working there because the hours and location worked better for her as a working mom. She was just as competent as the doctors at any private clinic.

Oh, and I the last doctor I went to while a student at Hall Health was a medical resident who started a practice family practice, which is where I now go for my medical treatment.

Anyway, that is not pertinent to the problem that the pharmacy at another university (which does not have a medical school) gave out (or sold) expired antibiotics. This is unacceptable, even for Whatcom County.

Skeptigirl, while your son does not have cause to bring legal action against WWU, the least your son can do is go back to the pharmacy and ask them why they gave him expired medication.

By the way, the student that Skeptigirl refered to was not treated at the university but at St. Joseph Hosp (http://www.peacehealth.org/Whatcom/NW_vital_stats.htm)ital:
http://seattlepi.nwsource.com/local/6420ap_wa_mrsa_death.html
... they gave him massive doses of antibiotics, which should have been up to date (since I bet they were intravenous).

It is also a reminder that college students, due to the close quarters they live and party in, need to keep up their influenza, meningococcal and other vaccines up to date.

[biostudent]

It is interesting that some countries have doctors/clinics associated with universities. This isn't the case in my country.

Perhaps it is only of relevance when Universities become really, really big?

I think it's more a consequence of being in a really big country. Students sometimes have to move pretty far away to go to school, and they need doctors... (that is definitely the case at my university. Students not only come from all over the country, but they come from other countries as well. Local doctors are not always able to take them on as patients.)

Skeptigirl: Tell your son that he needs to make a stink about it so that no one else gets hurt.

[biostudent]

It is also a reminder that college students, due to the close quarters they live and party in, need to keep up their influenza, meningococcal and other vaccines up to date.


;)

[Hydrogen Cyanide]

Sadly a young man just died up at Western WA University of MRSA pneumonia (http://www.king5.com/localnews/stories/NW_022108WAB_wwu_mrsa_death_TP.15c8de4c.html). ....

Message from that TV news story: wash your hands!

(oh, and in case you missed my earlier message, make sure your vaccines are up to date)

[Jorghnassen]

Of two, thank you. (My graduate and undergraduate schools weren't even in the same time zone.) The actual sample size is more like seven.... and I'm afraid that I have NEVER met a competent physician, pharmacist, or nurse at a university clinic.

Actually, while I never used the medical services at my alma mater, everyone else who did found the doctors there incompetent... And anyone needing medical attention at my current place of employment usually go to Toronto. So that's a few more completely independent anecdotes.

I should add that dentists establishing practices around university campuses are also not to be trusted.

[OnlyTellsTruths]

I was going to add a few more examples of low standard health care services at Universities before I stopped to think of other normal (City) hospitals I’ve been to as well.

It seems it may have more to do with the size of the population the hospital is serving, whether it be a city or University. If it serves below a certain minimum population (and possibly above a certain max. pop.) the standards drop exponentially. This may possibly explain the conflicting observations so far in the thread.

Though, it should be noted, cities and Universities would likely have different min. and max. ranges since most Universities operate at a lower capacity (usually quite low, below 10%) for 1/4 of the year (usually summer months). It varies how this is reflected in population figures (census returns).

This per-capita standards issue seems to also be the case with the schools themselves (education at all levels really), not just health care.

As for the OP, sorry to hear of anyone being exposed to such hazards. It may help some, who can't completely relate with expired medication, to imagine finding out a restaurant you frequent was serving several year old meat. With a lapse that large, someone involved must have some responsibility (civil, legal, or both).

Everyone should be attentive everyday in making sure organizations (businesses, utilities, etc.) operate correctly and safely, as well as being on the lookout for outright scams and illegality.

[BlackKat]

First hand experience with MIT's medical services. While I was not there as an adult, but rather a child seeing a pediatrician. I can say that they are hands down the best set of doctors and healthcare workers I've ever seen.

The problem with making blanket statements is that they are often incorrect (yes I know that I just made a blanket statement). ;)

Just as two hospitals literally next door to each other can be worlds apart in their quality of care, so too can clinics. There are competent and incompetent doctors everywhere, sometimes in the same office or department.

And this is quite the appropriate forum for this discussion as:
a) It's a medical topic
b) It's skeptigirl - who has made positive contributions to EVERY medical thread on this forum as long as I have been here and surely longer than that

[Deetee]

I am livid. A few months expired, it happens. A year, maybe. But expired 6 years ago and capsules clumped together in the bottom and not working!!!. This is unacceptable.

Think about it. What if my son had MRSA and they gave him antibiotics that should have been trashed 6 years ago? This is a perfectly acceptable forum to discuss the ramifications of a medical issue.
DD: it was actually you who brought up the medico-legal aspects with your suggestion to sue, and therefore took the discusion into this area .

Several points- The doctors who prescribed the doxycycline may not have given the best advice - "carry on even though it has got worse", but there may be some logic behind it as bad acne does often need quite prolonged course of antibiotics. (In homeopathy this is called an aggravation, and is a sign the treatment is correct! :))

The error was made with the dispensing in pharmacy - does no-one there check the drugs they stock? Time expired drugs should never be dispensed. Its OK to use most drugs after their expiry date -they are likely to remain effective for quite a long time after this, but 6 years is ridiculous. There must be a way to take this complaint back to the dispensers and the student health service - they must wake up and do something about it.

Doxycycline is actually one of the few antibiotics effective against MRSA.

[Ivor the Engineer]

Perhaps the Pharmacist trained here in the UK:

http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2006/04/20/nuni20.xml&sSheet=/news/2006/04/20/ixhome.html

A university has been caught lowering a pass mark to 26 per cent to prevent widespread failure of students, a landmark ruling under the Freedom of Information Act has disclosed.

The proof that up to 14 per cent was arbitrarily added to the scores of trainee pharmacists to save the university's reputation has renewed concerns over the dumbing down of degrees in the move toward mass higher education.

...

De Montfort, a former polytechnic, had denied claims that pass rates were manipulated, but material obtained by The Times Higher Education Supplement, published in today's edition, shows that marks were raised for five modules, one of which was maths, an essential component of the training of hospital and high street pharmacists.

:D

[Rocko]

Yeah, I was going to say - surely in the US drugs are dispensed by pharmacists, not the doctors themselves? In which case, the fault for this must lie entirely with them?

[Professor Yaffle]

At least in the UK, student health services often stock their own drugs rather than giving a prescription to be filled by the pharmacy.

Regarding the OP, I have just finished reading Bodies by Jed Mercurio, so nothing surprises me...

[technoextreme]

Yeah, I was going to say - surely in the US drugs are dispensed by pharmacists, not the doctors themselves? In which case, the fault for this must lie entirely with them?
It depends. In this situation I wouldn't be surprised that the doctor himself dispensed the medication on a daily basis. They do it with TB and I wouldn't be surprised that they do it with other diseases. The antibiotics are so potent that they can wreck havoc with your body and the disease itself can't be fun if you screw up the treatment.

[geni]

It is interesting that some countries have doctors/clinics associated with universities. This isn't the case in my country.

Perhaps it is only of relevance when Universities become really, really big?

Probably more to do with nationalised healthcare. While in the UK you may have a GP clinic that acts as the de-facto univeristy clinic if students are living off campus they may well register with local GPs. Since students tend to fairly healthly (and when not healthly it tends to be more an A&E issue) I'm not aware of this causeing a problem).

[skeptigirl]

....
Doxycycline is actually one of the few antibiotics effective against MRSA.For the common community acquired strain, USA 300, several classes of drugs are still effective, including tetracyclines and trimethoprim-sulfa. One of my concerns here is like in many places, the USA 300 strain has been a growing problem in the Seattle and Vancouver areas (http://www.cbc.ca/health/story/2008/02/10/bc-superbug-study.html) in the IV drug abusers for 5-6 years. (WWU is in Bellingham, between those two cities.) Giving someone 6 year expired antibiotic that CA MRSA is still susceptible to in an area with many MRSA cases is practically a crime since it is begging to increase the scope of drug resistance by undertreating the infection.

The young man who died no doubt was treated with IV vancomycin. Look at this article on the USA 300 strain. Intermediate Vancomycin Susceptibility in a Community-associated MRSA Clone (http://www.cdc.gov/EID/content/13/3/491.htm). This was published in the CDC's Emerging Infectious Diseases a year ago. We describe a case of treatment failure caused by a strain of USA300 community-associated methicillin-resistant Staphylococcus aureus (MRSA) with intermediate susceptibility to vancomycin and reduced susceptibility to daptomycin. The strain was isolated from the bone of a 56-year-old man with lumbar osteomyelitis after a 6-week treatment course of vancomycin for catheter-associated septic thrombophlebitis.

That expired doxy was practically criminal in my book.

HC, I know the death occurred in the hospital. I have actually contacted someone up there to share my information. What I was saying was there is an outside chance the kid went to the student health center when he initially became ill. They may or may not have treated him if they did see him and it may or may not have involved expired drugs. Chances are nothing from the student health directly contributed to the kid's death. But I think it was important for the people investigating the death to at least be aware of the problem. Then if there is a record he was seen at the student clinic they can follow up there as well.

BTW, for those of you flu vaccine naysayers, there's about a 99% chance even with the mismatch of vaccine this year that the influenza vaccine could have saved this kid's life. His initial infection was influenza from what I understand. Even if it didn't prevent the infection, the flu would have still likely been milder. His is the second death in a young person attributed to influenza in our state this year.

Health Advisory: Influenza-Associated Pediatric Mortality and Staphylococcus aureus co-infection (http://www.metrokc.gov/health/providers/epidemiology/health-alert-080131.htm)From October 1, 2006 through September 30, 2007, 73 deaths from influenza in children were reported to CDC from 39 state health departments and two city health departments. Data on the presence (or absence) of bacterial co-infections were recorded for 69 of these cases; 30 (44%) had a bacterial co-infection, and 22 (73%) of these 30 were infected with Staphylococcus aureus. The number of these deaths in which pneumonia or bacteremia due to S. aureus was noted represents a five-fold increase over the 2 previous influenza seasons. No pediatric influenza deaths have been reported to-date this season locally.That was a county news report for January.

Here's a state news report for February Recent respiratory deaths prompt state disease prevention reminders - Whatcom County investigating death attributed to MRSA-pneumonia (http://www.doh.wa.gov/Publicat/2008_news/08-022.htm)A 20-year old student at Western Washington University died Thursday from what local health officials have identified as MRSA-pneumonia, which is rare. Last week, an 18-year old Pacific County resident died from respiratory failure. The cases are not linked.The 18 year old was reported as influenza death. He didn't have MRSA pneumonia and I do not know if he had any health problems that contributed to the death.

[skeptigirl]

double post deleted

[skeptigirl]

Yeah, I was going to say - surely in the US drugs are dispensed by pharmacists, not the doctors themselves? In which case, the fault for this must lie entirely with them?If you get a prescription you take it to a pharmacy and the pharmacist or a pharmacy assistant dispenses it. And there are even laws limiting how I as the prescriber can dispense drugs directly to patients.

In this case the clinic dispensed the drug. That means either the provider who prescribed the drug also dispensed it, or the provider told someone else in the clinic to dispense it. That someone would have to be licensed as well like a nurse. They are all supposed to know better and you are supposed to check expiration dates, not only when you hand it to the patient, but also you need a system of checking the drugs on the shelves for expired drugs.

This was a failure in many ways.

[skeptigirl]

At least in the UK, student health services often stock their own drugs rather than giving a prescription to be filled by the pharmacy.
...At least? That can actually increase errors such as in this case. The pharmacy acts as a system check.

Though errors in transcription increase when the pharmacy fills prescriptions rather than providers dispensing the drugs.


Edited to add, Oh, I see Ivor's post now. :)

[skeptigirl]

Actually several years ago I knew a doctor who worked at Hall Health Center (university medical clinic named for a person whose last name was "Hall"). She was a real doctor who was working there because the hours and location worked better for her as a working mom. She was just as competent as the doctors at any private clinic.

Oh, and I the last doctor I went to while a student at Hall Health was a medical resident who started a practice family practice, which is where I now go for my medical treatment.

Anyway, that is not pertinent to the problem that the pharmacy at another university (which does not have a medical school) gave out (or sold) expired antibiotics. This is unacceptable, even for Whatcom County.

Skeptigirl, while your son does not have cause to bring legal action against WWU, the least your son can do is go back to the pharmacy and ask them why they gave him expired medication.

By the way, the student that Skeptigirl refered to was not treated at the university but at St. Joseph Hosp (http://www.peacehealth.org/Whatcom/NW_vital_stats.htm)ital:
http://seattlepi.nwsource.com/local/6420ap_wa_mrsa_death.html
... they gave him massive doses of antibiotics, which should have been up to date (since I bet they were intravenous).

It is also a reminder that college students, due to the close quarters they live and party in, need to keep up their influenza, meningococcal and other vaccines up to date.
Oh my Gawd! Look at this from the PI article!His roommate had taken him to the school clinic on Feb. 14.Now I am really going to get loud!!!

Tomorrow, I will personally call the Whatcom County Public Health officer investigating the case.

My son will be going back to the clinic to complain Monday as well. He didn't want to contact the school paper but he was definitely going back to the clinic. And he has a new camera so he is going to take pictures of the bottle and clumped pills before taking it back to them.

[annexw]

I'm a bit confused as to how he knew the antibiotics were expired.

Admittedly I'm in a different country and perhaps we do things differently here, but when I get a script for antibiotics (many tooth infections. Ouch) I take the script to the pharmacy and they type up the label, stick it on the bottle and count out how many pills I'm meant to have. The pills come from one of the giant pill bottles in the back.

Honestly, if I saw that the expiry was 2002, I would first think "huh?", then "Meh, typo". Maybe I'm wrong and the label is auto-generated, but that seems pretty high-tech for my punty pharmacy.

Occasionally, the gel-coating on the pills clumps them to the bottom of the pill case due to the heat in my car/office/bag.

Also, I *always* get the spiel about taking all my antibiotics. Something about trying to limit antibiotic strains and people stopping taking their pills when they feel better even though there is still an underlying infection. I thought this was a standard pharmacy spiel? Again, perhaps I'm wrong.

I only have my consumer knowledge to go by here so maybe I'm out of line, but did your son actually check with the pharmacy that the lot was expired? If they were, then a jump to the telling the paper would not be out of order, but it could have been something as simple as a typo.

Oh, I was typing as you were posing, I see he is going to the clinic. That seems logical. Good luck in finding some answers.

[skeptigirl]

I'm a bit confused as to how he knew the antibiotics were expired.

Admittedly I'm in a different country and perhaps we do things differently here, but when I get a script for antibiotics (many tooth infections. Ouch) I take the script to the pharmacy and they type up the label, stick it on the bottle and count out how many pills I'm meant to have. The pills come from one of the giant pill bottles in the back.

Honestly, if I saw that the expiry was 2002, I would first think "huh?", then "Meh, typo". Maybe I'm wrong and the label is auto-generated, but that seems pretty high-tech for my punty pharmacy.

Occasionally, the gel-coating on the pills clumps them to the bottom of the pill case due to the heat in my car/office/bag.

Also, I *always* get the spiel about taking all my antibiotics. Something about trying to limit antibiotic strains and people stopping taking their pills when they feel better even though there is still an underlying infection. I thought this was a standard pharmacy spiel? Again, perhaps I'm wrong.

I only have my consumer knowledge to go by here so maybe I'm out of line, but did your son actually check with the pharmacy that the lot was expired? If they were, then a jump to the telling the paper would not be out of order, but it could have been something as simple as a typo.

Oh, I was typing as you were posing, I see he is going to the clinic. That seems logical. Good luck in finding some answers.These are good questions, I asked them myself, but I'll explain how we know.

Sometimes you get the original bottle with the original label and the patient label is affixed over it. Not this case. But I asked my son, was the label with his name separate from the label with the date? And it was. I mentioned before about the rules for dispensing drugs without using a pharmacist. What the clinic does is get the prescriptions ready, label them with the drug, amount in the bottle and expiration date. Then you either fill in the patient's name by hand, or add an additional label with the patient's name to the bottle.

This clinic got the pre-prepared bottle of capsules off the shelf and wrote my son's name by hand on the label. With the pills being clumped up, the drug not working, and the way I know a clinic prepares drugs to be dispensed without a pharmacist, I'm pretty sure the 2002 date was accurate. Sometimes you put 12 months from the time you make up the pill bottles for an expiration date. But still the real exp date wouldn't be that long for doxycycline. It doesn't have a 6 year shelf life.

As for your own capsule clumping experience, I'd look into that. If moisture is getting into the bottle, that could actually affect the drugs in the capsules. Those soft gel caps will stick to each other like vitamin E or fish oil, that is not a problem. But hard gel caps like the ones antibiotics are in should not be sticking together.

[annexw]

Thanks skeptigirl, that all makes sense. I appreciate the answers.

I have never seen pre-packed pills, but all mine have been from a pharmacy and not a clinic. To be honestly I didn't even know clinics could do that (maybe in Canada there are different rules). The pills I had were gel caps like...um...Tylenol gel caps or Advil. I think those would qualify as the soft ones. :)

It would seem you have some extremely valid concerns. I hope your son finds something out.

[skeptigirl]

Soft gel caps are squishy like they have fluid inside. Regular gel caps can be easily crushed and they might rebound into shape but they are not really squishy like soft caps.

Vitamin E, fish oil, flax seed oil and stool softeners like colace or ducosate come in soft gel caps. I have not seen Tylenol or Advil in soft caps. If they are sticking together I suggest you keep the little dehydrator packet you find in the bottle in there or make sure you are putting the lid on tightly. They really shouldn't be sticking together even in the heat. It's not a huge deal with over the counter pain meds. Either those work or you know they are not working. But for prescription meds, you could be getting a sub-therapeutic dose from improper storage and not know it.

Doesn't matter if my son takes up this cause, Mom's going on a rampage. :) I feel terrible that the student health care is substandard and I am going to make a polite but huge stink over it. What if it contributed to the other kid's death? What if the care is really bad there? I am not letting this go unnoticed. It's like I said, a couple months past the expiration date is a med error that happens, it shouldn't but people are human. Six years past the pull date is not a simple human error. It is negligence and/or incompetence.

[Professor Yaffle]

Clarification - when I said "at least" in my previous post, I just meant that I only knew about the UK, and not about any other countries. I was'nt saying anything about whether I thought this was a good state of affairs or not, but I see now how it could be read like that.

[biostudent]

Thanks skeptigirl, that all makes sense. I appreciate the answers.

I have never seen pre-packed pills, but all mine have been from a pharmacy and not a clinic. To be honestly I didn't even know clinics could do that (maybe in Canada there are different rules).

It can happen in Canada. It just doesn't happen very often. I always prefer to fill my prescriptions at an actual pharmacy because clinics (and even hospitals) always just sort of magically produce pills in record time, which has always bugged me. Pharmacists count out the pills in front of you, so at least you know where they came from.

[Asolepius]

Not wishing to worry you even more, but if the capsules really were that old there is a substantial risk of Fanconi syndrome (http://www.emedicine.com/ped/topic756.htm).

[skeptigirl]

Not wishing to worry you even more, but if the capsules really were that old there is a substantial risk of Fanconi syndrome (http://www.emedicine.com/ped/topic756.htm).Actually I'm glad you found an actual source for this info. I had just read it on a couple of answer pages that didn't offer much in the way of checkable sources for the info. And this is important.

But now I have an image of the bottle from my son and while the date does look like 02, I checked with the distributor and from the lot number it turns out to have expired in 05/2008 not 2002. It also is the label from the distributor and not one created by the clinic.

So, I am calm again. I'm glad it didn't turn out to be as bad as it looked. ButTetracycline toxicity is probably caused by anhydro-4-epitetracycline, a degradation product that is formed when the drug is stored for long periods or kept in a moist environment. The metabolite decreases oxidative metabolism and energy production. is still an issue.

There is still the issue of proper storage before dispensing the pills. They are clumped together and it also turns out these are not capsules, they are enteric coated pills.

The enteric coating is chipped off many of the pills. The typical shelf life is 2 years. So this bottle has been on the shelf close to 2 years either at the distributor or in the clinic. The chipping shows a lot of handling, but probably doesn't significantly hurt the pills.

The clumping together, OTOH, does indicate exposure to moisture which does affect the potency of the pills. Hopefully breakdown due to moisture wasn't enough to cause the degradation mentioned above. So a replacement supply is still in order.

Sorry for two pages of a theoretical medical problem rant. :(

[Asolepius]

But now I have an image of the bottle from my son and while the date does look like 02, I checked with the distributor and from the lot number it turns out to have expired in 05/2008 not 2002. It also is the label from the distributor and not one created by the clinic.(In other words, it hasn't expired at all? Or did I blink and miss half of this year?:)

[The Gnomon]

My recommendations:
1. Never go to a physician who dispenses her/his own medication (excepting, of course, highly qualified specialists administering treatments in a hospital or similar setting)
2. If your medication isn't working, don't take someone's word that you should just keep on with it - get an expert opinion.
3. Don't go to any office or clinic without checking on the credentials of the professionals. Contact your state licensing board (or web site) to check.

A college student is intelligent enough to be able to find out reliable information. Do it.

[skeptigirl]

Gnomon, I dispense meds all the time. I dispense prophylaxis for infectious disease exposures as well as treat latent inactive TB. Sending my patients to a pharmacy would incur unnecessary expenses for such routine treatments.

Of course people should get advice of professionals. But I also encourage my patients, buyer beware. In medicine that essentially means ask questions, look at labels, and sometimes get second opinions for things when you are not getting better and you feel you are not getting satisfactory answers.

(There is a balance there. Sometimes people just keep going to different providers until they get the answer they want rather than the correct answer.)

In this case I am not concerned the clinic is staffed by unlicensed professionals. But I am concerned about quality of care. I'll see what they have to say about the storage conditions of the doxycycline when my son goes back to the clinic.

[skeptigirl]

In other words, it hasn't expired at all? Or did I blink and miss half of this year?:)Apparently it was a case of a poorly printed date that looked like a 2 but was an 8 after all. It does look like a 2, I have the image he sent me. But the bottle had a lot number that was readable. I called the distributor and said, "it was a drug my patient was taking from another clinic and I couldn't read the date".

Here's a tip for you all. When you call a distributor or drug manufacturer, never let on you are the patient. They immediately clam up. But if you say you are a provider they are helpful. In the latter case you are a customer or a potential customer. If you say you are the patient they don't want to say anything that might upset the provider who is their customer.

[biostudent]

Here's a tip for you all. When you call a distributor or drug manufacturer, never let on you are the patient. They immediately clam up. But if you say you are a provider they are helpful. In the latter case you are a customer or a potential customer. If you say you are the patient they don't want to say anything that might upset the provider who is their customer.

Creepy, but thanks.