Eight-year-old Buddy was a lively boy with a beautiful laugh. Because of a sleep disorder, he took medicine every night to help keep his sleep cycle regulated. One night his mother gave him his medicine as usual and put him to bed. When his father went to wake him in the morning, Buddy was dead. Medics told Buddy’s parents that their child had been dead for hours. Months later, an investigation by the coroner revealed that instead of his usual medicine, L-tryptophan, Buddy had toxic amounts of a powerful muscle relaxant drug called Baclofen in his system. Buddy had died from a medication mix-up.
Upon analyzing the medicine remaining from Buddy’s prescription, the coroner found that the amount of medicine was precisely the amount required to produce the L-tryptophan mixture – but it was the wrong drug. Someone in the lab had mistakenly used Baclofen powder instead of L-tryptophan powder. The resulting liquid contained enough Baclofen to kill an adult, but it looked and apparently tasted the same as the L-tryptophan mixture. Once the mistake was made, it was impossible to tell the difference.
Buddy’s parents have begun a campaign to require reporting of medication errors to a database in the province they live in, and they hope that other provinces will follow suit. While pharmacy errors are believed to be rare in their high-income country, the actual number and type are not known because only one province now has such a requirement. “I think that when there is transparency, training can happen, review of policy and procedures can happen, intervention can happen”, Buddy’s mother said. “Nothing can bring Buddy back to us. However, in his caring spirit we want the laws to protect all people,” she concluded.
*The names and photos used in this story are not real, but the story is based on true events.