Penicillin nightmare for DS! (almost)

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My 8 yo DS is allergic to penicillin and sulfa-based medications. We found out when he was 2 yo and when he had a severe allergic reaction to amoxicillin after he got his first ear infection. I always have to keep reminding his pediatrician's office when he needs an antibiotic that he cannot have penicillin.

On Sunday he woke up with a sore throat and was vomiting all day. On Monday his throat was worse and he was in tears. I had to go back to work (first day back teaching and of course my DS gets sick!), so my mom stayed with the kids and took DS to the doctor. When I made the appointment, his regular pediatrician was all booked up so the office asked if a nurse could see him just to do a throat culture and I said that was fine, because it was either that or just a virus. When my mom took him in, the nurse asked if DS was allergic to any medications (hello, isn't it in his chart?). My mom told her that yes, he was allergic to penicillin.

The rapid strep test came back positive so the nurse called in a prescription. My mom picked up the medicine and brought it home. She shook the bottle and measured out the dosage into one of those plastic things the pharmacy gave her. She was getting a cup with some water from the fridge for DS, when DS picked up the bottle and read "A-mox-a cill-in." My mom had no idea that Amoxicillin was a pencillin-based medication, but something in her thought to read the paper that came with it just to be sure. Right away she saw on there that the medicine should not be taken if there is a penicillin allergy.

Long story short, she called back the pharmacy, who called back the doctor's office and waited 5 hours to get the right medicine. When she told me about it at 3:30, I was furious!!! :mad: I called that nurse and asked her if my mom had told her that DS was allergic to penicillin and the nurse said, "Yes, she told me but I saw on his chart that he was given Amoxicillin in 2001 so she thought it was really okay. I said, "YES, THAT'S WHEN WE FOUND OUT HE WAS ALLERGIC!!" His whole body was one big hive and he had labored breathing and was taken to the ER. She took full responsibility and and apologized.

How can I stop this from happening again??? His chart should be flagged so that these people don't end up killing my son one day!! I called the pharmacy and they now have his file flagged there. My mom used a different pharmacy than where I usually go, so they had no idea.

I'm just so upset and can't even think about what could have happened had DS taken that medicine!!! Should I file a complaint with my insurance provider? I know they send us surveys in the mail every time someone goes to the doctor, but since he just saw a nurse, I don't know if I'll ever get a survey.

Sorry so long winded. Has this ever happened to anyone else?
 
WOW, no ideas on how to help, but that's crazy!

I'm allergic to penicillin also. My parents have told me this since I was small - I'm 43 now. I had once doctor ask me recently what reaction I have when I receive penicillin...ummm...not sure, doc, haven't had any in over 40 years so I don't really remember. But trust this -- I'm CERTAINLY not about to try it again now!
 
Wow, that's scary! I would bring in a big red piece of paper that says not to perscribe any penicillin or sulfa-drugs for your son and ask it to be put in the front of his folder. Something that will catch attention.

Does he wear a medic alert bracelet? I always worry about what would happen if he had to be taken to the hospital or something when you weren't there (maybe at a friend or relative's house).
 
I am allergic to the "cillins"--that is first what I would advise your family members. If it rhymes with penicillin, he can't have it.


I am shocked that your pediatrician's office is that "airheaded".

My kids saw my family doctor and they code all patients similarly---my chart has a bright red sticker on it with my pharmaceutical allergies on it. To not notice would be malpractice.

I would rip the office a new one if it were me. Especially since they have a history of needing to be reminded.:sad2: You can also purchase a medical bracelet for your son. To wear at least while he is a kid. then at least medical staff might read it.
 

How can I stop this from happening again??? His chart should be flagged so that these people don't end up killing my son one day!! I called the pharmacy and they now have his file flagged there. My mom used a different pharmacy than where I usually go, so they had no idea.


I am flagged at my pharamcy as well. I required an antibiotic when I was pregnant and b/c of my morning sickness I could only swallow liquid which unfortunately limited me to that family of antibiotics. Doctor had me take it with an antihistamine. But b/c I was flagged at the pharmacy, they called it to my attention and there plain as day on my medicine when I picked it up was a HUGE note stapled to the bag advising me that I was allergic. (I was fine taking it with an antihistamine, but very very smart of the pharmacy to have that on file--they ask when you get your first meds if you have allergies and then notate it).

As far as what you can do---I'd shop for a new pediatrician. Frankly if they cannot remember something as simple as what will make your son quite ill after several reminders, it just isn't a place I would want to take him. KWIM?
 
Wow. That's completely unacceptable. Can you file a complaint against the dr. with your insurance co? I did this with a previous physician who made several dumb mistakes, fortunately none life threatening. He was put on notice and eventually dropped by the insurance co. after receiving a number of complaints from other patients. Thank goodness your son was able to read the label and your mother had the good sense to read the information.

I agree about getting the Medic Alert bracelet. You never know when there might be an emergency that you aren't able to get in contact with the hospital/physicans, and he's unable to speak for himself. I have Medic Alert for 2 of my kids who have life-threatening peanut/tree nut allergies. It's a great service.
 
I would definitely complain to someone, that is unacceptable.

My DD is allergic to the 'cillins too. She had been on Augmentin for 4 days twice a day before she started to breakout. At first they looked like a bunch of tiny mosquito bites, I called the drs. office and I told her that I thought she might be allergic to the medicine (my DH, FIL & SIL are all allergic to the penicillins too) and wondered if I could bring her in to be checked. The nurse said there was no way she could be allergic to it since she had already been taking it for 4 days. She said they closed in 1.5 hours and there was no way that they could fit her in. She also said to keep giving her the medicine and she thought that there may be a mosquito in my house. I decided I wasn't given her another dose of the medicine b/c I just "felt" like she was having an allergic reaction. Within a couple of hours, she looked like she had been burned in a fire her welps were that big and they were blue underneath like she had been beaten up. She looked horrible. We rushed her to the ER and they said it was an allergic reaction and they couldn't believe what the nurse had told me on the phone. Needless to say 2 days later when I took her to the doctor for her re-check and told them what had happened they said that they were sorry and they would inform the nurses of what had happened. I felt like that was not enough and that they didn't care. I felt like if I had kept giving the medicine like the nurse said -- it could have killed my DD. I hold drs & nurses to higher standard than that. I told them that day that I wouldn't be back and I found another pediatrician that day.

I believe at the new doctor her chart has a red sticker on it. Anytime she has had to have a prescription as soon as they start talking about it I mention she has the alllergy and they always say, "I know -- it's on the chart".

Good luck in what ever you decide to do!
 
I am sorry that happened to you. I am a nurse and I am so upset when things like this happen. I work in ICU know, but I used to work in the ED. It is a problem with children as well as adults. People need to take a piece of paper and write their medical info and put it by thir driver's lic and it is just as important that people who watch your children have a list of parents phone numbers for emergency, any medical problems, medications they are on if any and allergies, with what the reaction date is and when it occured. So many times people don't know this information and it can be valuable. It is true, doctors go to the medical record to see if a person had a reaction to a medication. When allergies are reported, the date needs to be listed as well, and it sounds like this wasn't done. If it were me, I would write a letter to the office manager of your physicians office. That person will investigate and will let the doctor know what happened. The doctor's are so busy with all the paper work they do, that your letter may not be looked at as quickly if you sent it directly to him or her.

When we do our admission assessment, we ask allergies. You would not believe how many people who know that they are allergic to something and don't know what it is, or why it was given to them before. They sometimes know what type of reaction, but it is hard to tell what it was. It maked it difficult for healthcare providers to care for them.

My son is allergic to penicillin too. He has amoxicillin several times, and then had a reaction to the penicillin VK. When the nurse put the penicillin allergy on his chart, I asked her to write the date beside it so it was clear. I also told the pharmacist at the pharmacy we use, so they could record it in their file.
 
Not sure about what you can do at the doctors office, but let the pharmacy know, they can flag it in the computer to alert them if he's allergic to the meds. Wow, thank goodness your son was able to catch that:eek:
 
Writing to the office is a big thing. I suggested writing to the office because the nurse didn't do her job properly. The nurse is the patient advocate and should have checked properly. I feel that it more of the nurses faultthan the doctor's. If she had been doing her job properly, it would have never happened. I will also say that some offices don't have RN's or even LPN's, they have medical office assisntants which have even less education than a LPN. Let them know you are upset. Ask for a response, also, I would send a copy of the receipt for what you paid for the wrong medication. I would ask them to reimburse you for that, even though amoxicillin is very inexpensive.
 
Thanks for all the responses. I am going to call my insurance company and the dr.'s office manager tomorrow and complain. Maybe they've been having problems with this nurse for awhile, so the more documentation they get, the easier it will be for them to get rid of her.

Since we only went in to see the nurse (and not the doctor), I probably won't be getting any kind of survey from our insurance company. We love the doctor -- the kids have been with her since they were born and she is great. The problem is that 1/2 the time we end up seeing someone else in the office. I need to make sure they flag his file with a big red sticker.
 


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