B.C. woman's demise exposes dangers of 'alert fatigue' among pharmacists
Ernie Lambert is going public because he feels the system of checks for dispensing prescription medicines failed his mother, Helena, and he wants to warn other patients. (CBC)
A B.C. man is going public to warn others after his mother was killed by an adverse interaction between two prescription drugs, a well-known risk that was overlooked by health professionals she trusted.
"There was a physician and two pharmacists and a computer system that all failed here. It’s not a simple mistake,” said Ernie Lambert, whose mother died in 2012.
Helena Lambert's local pharmacists dispensed the medications without noting or warning of the potential problems of taking them concurrently, even though widely-used software at the pharmacy would have flagged the potential adverse interaction.
"The procedures weren’t followed. What [electronic] warnings there were, were ignored," Ernie Lambert said.
"She wasn’t going anywhere without a fight. The problem is, this wasn’t a fair fight. She didn’t have a hope."
Helena Lambert, from Creston, B.C., was 76, and healthy and active for her age, when she was prescribed allopurinol to treat her gout. She was already on mercaptopurine, an immunosuppressant, for colitis.
Lambert says he still can’t come to terms with how much
his mother, Helena, suffered, and why. (Ernie Lambert)
Six weeks after starting her new medication — just home from a holiday with her children and grandchildren — she developed a blister on her foot.
Ernie Lambert took his mom to the Creston Valley Hospital, where doctors determined the interaction between the two drugs was causing her immune system to shut down.
"The doctors there figured out very quickly what had gone wrong," Lambert said. "They were as appalled by this as I was, because of these two drugs and how well known the interaction between them is."
The doctors determined the blister was caused by a bacterial infection that spread quickly.
He said his mom suffered terribly, before dying from infection and respiratory failure.
"She was so frustrated and so angry," Lambert said, in tears. "It was a terrible struggle. It was a horrible way for anybody to die."
Lambert pushed for an investigation, and a B.C. coroner confirmed the drug interaction caused his mom’s death. He then filed complaints with regulators against the pharmacist and her doctor.
'Alert fatigue' revealed
Evidence submitted by the doctor, Kriegler Le Roux, suggested the death was a worst-case scenario, triggered by a growing phenomenon among pharmacists called "alert fatigue."That's when pharmacists ignore or turn off the flags in their computer systems — the ones that alert them to drug interaction risks — because they are overloaded by too many warnings, from mild to severe.
Le Roux, who prescribed both medications, told his regulator he relies on pharmacists to check whether there are known drug-interaction issues. He believes that in this case, the pharmacists didn’t even see the warnings in the system used at the Creston Pharmasave.
"The community pharmacist informed me that because there are so many potential interactions between medications, they have to tune down their [software] system not to flag less common or troublesome interactions," the doctor wrote to the College of Physicians and Surgeons of B.C.
"We need a better flagging system," Le Roux told Go Public.
He was criticized by his regulator for not adjusting Lambert’s drug dosages to reduce the risk when he prescribed the second drug.
"I definitely pay more attention to this now – and I tell my friends."
The pharmacists involved were each suspended for 30 days by the College of Pharmacists of B.C.
