Case Study: Alleged Dispensing of Wrong Medication Strength Results in Seizures, Hospitalization, and Claimed Loss of Independent Living
Indemnity Payment: $510,000
Legal Expenses: $28,000
Summary
Note: This case involves a 70-year-old male patient with a complex medical history and multiple comorbidities.
The patient had been a long-standing customer of a community pharmacy and, based on his medication regimen, had a complicated medical history that included a neurologic diagnosis, thyroid disease, cardiac disease, cognitive impairment, and anxiety/depression, among other conditions. Family members periodically contacted the pharmacy with questions regarding the patient’s medications and dosing instructions.
The incident occurred after the pharmacy received an electronic prescription from a specialist for amitriptyline 10 mg tablets, with directions to take two tablets by mouth at bedtime. The prescription was processed and dispensed; however, the medication provided was the incorrect strength—100 mg tablets rather than 10 mg. As a result, the patient began taking 200 mg nightly, ten times the intended dose.
Several days after dispensing, the pharmacist-in-charge (PIC) reviewed daily summaries, noted what appeared to be an unusually high dose of amitriptyline, compared it to the original electronic prescription, and identified the strength mismatch. The PIC proceeded to prepare the medication consistent with the prescriber’s original order. He then contacted the patient and delivered the prescription. However, he could not recall whether the incorrectly dispensed medication container was retrieved. Note that the PIC also reported contacting the prescriber’s office about the error. However, he did not document these corrective actions and communications. Furthermore, the PIC did not notify the dispensing pharmacist about the error.
On the day following prescription replacement (five days after the error) the patient experienced seizure activity and required emergency evaluation and hospitalization, including intensive care and ventilatory support. The complaint alleged that the overdose resulted in significant neurologic injury, cognitive decline, and loss of the ability to live independently, with subsequent placement in a supportive living setting.
Resolution
A lawsuit was filed against multiple defendants, including the dispensing pharmacist, the PIC, and the pharmacy. The dispensing pharmacist reported having no knowledge of the error until being served with the lawsuit. The defense acknowledged that a medication strength dispensing error had occurred, while disputing whether the patient’s long-term decline and need for supportive living could be attributed to the brief course of incorrect dosing, given his significant pre-existing medical conditions and prior neurological events.
During discovery the defense team found that at the time of the incident, the pharmacy’s workflow made it difficult to determine whether a pharmacist or technician selected the incorrect strength in the dispensing system. Contrary to best practices, the pharmacy’s process allowed technicians to work under a pharmacist’s active login credentials, with the pharmacist completing the final product verification.
Plaintiff experts opined that the overdose precipitated severe neurologic consequences, including seizure-related complications and a hypoxic event, and materially contributed to functional decline and future care needs, projecting significant long-term supportive care costs.
Defense experts, while not contesting that an error occurred, emphasized that the patient had documented neurologic and cognitive impairment predating the incident, including a history of seizures and treatment for cognitive decline. They opined that the patient’s subsequent deterioration more likely reflected progression of underlying disease and comorbidities rather than a discrete medication-related injury. The defense also challenged whether the hospitalization course supported the claimed hypoxic brain injury.
The matter involving the dispensing pharmacist resolved by settlement at mediation, with a total incurred amount (settlement plus claim expenses) of approximately $538,000. Allegations against other defendants were resolved separately, with outcomes not disclosed.
Risk Management Comments
This event illustrates a high-severity vulnerability common in community pharmacy operations: selection of an incorrect medication strength from electronic drug systems, followed by workflow and technology gaps that allow the error to pass through final verification. The discrepancy appears to have occurred during order entry or product selection, and the final check did not detect that the dispensed strength differed from the prescribed strength.
The case also highlights a significant operational risk when multiple staff members can work under a pharmacist’s active system credentials. This practice complicates reconstruction of events following an incident and may support a plaintiff’s assertion that accepted operational and security practices were not followed, weakening the defense.
Reliance on a single end-stage verification—particularly in a high-volume, interruption-prone environment—may not provide the reliability of a truly independent double-check or effective technological mitigation.
The PIC’s later identification of the dose error during retrospective review demonstrates the value of auditing processes; however, the timeline underscores why safer systems are designed to intercept selection and strength errors before medications reach the patient.
Risk Management Considerations/Recommendations
As human beings, pharmacists and all healthcare providers may make mistakes. Therefore, it is essential to develop and implement systems and methods to reduce potential errors and related adverse outcomes. Consider the following risk management recommendations, among others:
1) Strengthen barcode-supported verification during prescription production
Technology-based verification tools can play a vital role in preventing wrong-drug and wrong-strength errors. Incorporating barcode scanning of stock containers and packaged products during the filling process helps ensure that the selected medication and strength match the prescription being dispensed.
Pharmacies should establish clear expectations that barcode scanning is a routine safety step, regularly monitor compliance, and address workflow or system issues that contribute to alert overrides or workarounds. Limiting prescription production to one patient at a time—rather than printing and filling labels for multiple patients simultaneously—can further reduce selection and mix-up errors during busy periods.
2) Incorporate dose and strength “reasonableness” checks for medications with wide dosing ranges
Medications available in multiple strengths present increased risk for selection errors, particularly when dose differences are substantial. Pharmacy systems and workflows should prompt additional scrutiny when an entered dose or strength appears atypical for the patient, such as a large initial dose or a significant increase from prior therapy.
Practical safeguards may include system alerts for unusually high doses and a deliberate pharmacist verification step requiring comparison of the original prescription with the final label and selected product, including drug name, strength, and directions for use.
3) Strengthen the final verification process—make it meaningfully independent
In this case, the pharmacist was expected to verify the filled prescription against the stock bottle and prescription, yet the strength mismatch was not detected. Standardizing the verification process to explicitly include confirmation of medication strength, not just drug name, may reduce similar errors.
Using a structured “pause point” with minimized interruptions during final verification — particularly for new starts, dose changes, elderly patients, or polypharmacy — can improve reliability. Where feasible, adding a second qualified check for high-risk prescriptions may further reduce risk, provided it functions as a truly independent review.
4) Eliminate shared credentials and improve auditability
Allowing technicians to operate under a pharmacist’s active login complicates accountability and limits the ability to identify process failures after an event. Pharmacies should require unique system credentials for all staff, align permissions with job roles, and periodically review audit trails for unusual patterns or vulnerabilities.
5) Engage the patient or caregiver at pickup using structured verification
Engaging patients or caregivers at the point of sale provides an additional safety net. For medications available in multiple strengths, pharmacists may consider a brief, standardized counseling approach that includes review of the medication name and strength, the intended dosing regimen, and a teach-back question such as, “Can you tell me how you will take this medication when you get home?”
6) Learn from external events and hardwire improvements
Proactively reviewing medication errors and safety risks reported by external organizations can help pharmacies identify latent vulnerabilities in their own systems. Incorporating brief safety huddles or periodic reviews of near-miss events, and translating lessons learned into concrete workflow or system changes, can strengthen overall medication safety.
This case demonstrates how a single strength-selection error, when combined with workflow vulnerabilities and complex patient factors, can result in allegations of significant patient harm and professional liability exposure. Pharmacists who pair professional vigilance with thoughtfully designed safety systems are well-positioned to prevent errors and patient harm.
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Disclaimer.
The information, examples and suggestions presented in this material have been developed from sources believed to be reliable, but they should not be construed as legal or other professional advice. CNA accepts no responsibility for the accuracy or completeness of this material and recommends the consultation with competent legal counsel and/or other professional advisors before applying this material in any particular factual situations. This material is for illustrative purposes and is not intended to constitute a contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All products and services may not be available in all states and may be subject to change without notice. Certain coverages may be provided by a surplus lines insurer. Surplus lines insurers do not generally participate in state guaranty funds, and insureds are therefore not protected by such funds. The claims examples are hypothetical situations based on actual matters. Settlement amounts are approximations. Certain facts and identifying characteristics were changed to protect confidentiality and privacy. “CNA” is a registered trademark of CNA Financial Corporation. Certain CNA Financial Corporation subsidiaries use the “CNA” trademark in connection with insurance underwriting and claims activities. This material is not for further distribution without the express consent of CNA. Copyright © 2026 CNA. All rights reserved. Published 05/2026.