It’s Saturday morning. Tess is getting up for the day. Except that she isn’t. She’s falling over. Constantly. Can’t keep her balance, walking into walls, falling on stuff. She can’t stand up on her own, can’t even think about going up or down stairs. We can’t figure out what’s going on.
It occurs to us that her ADHD medication, guanfacine, has recently doubled. It can affect blood pressure, so we think maybe that’s the problem. We sit with her all day, trying to keep her safe and still. She’s out of it. Pretty tired, and unable to stand or walk on her own.
That night, after we’ve given her all her evening meds, my wife figures it out. It’s not the guanfacine. It’s her seizure medication, Lamictal.
My Mistake
I fill Tess’s pillbox every week. She’s been on Lamictal since her seizure on New Year’s Eve. The thing about Lamictal is that it was a 25-milligram pill. Once we worked her up to her full dose of 200 milligrams, that’s 8 pills every night, which is a lot on top of her other medications. So I’d contacted her neurologist and asked if he could prescribe a higher dose per pill so she wouldn’t have to take as many.
What I didn’t realize is that he’d already done this. The new pills were 100 milligrams each. And I had refilled her pillbox with 8 of them. For four nights in a row, she’d been getting 800 milligrams when her dose should have been 200. Four times what it should have been. Because I didn’t look at the label.
The ER
We called poison control. They told us to go directly to the emergency room, where Tess would get an EKG to check the electrical activity in her heart. We drove to the ER, got right in, and the EKG results looked alarming. I’m no cardiologist, but I knew what I was seeing didn’t look good.
They gave her IV fluids, got her comfortable in a bed, and we waited. I was positively ill, thinking about my mistake. How careless it was. How I could have given her medication without looking at the label. How awful it must have felt for Tess over those days as the quadruple overload took effect. How avoidable this was.
Tess fell asleep around 8. We were there for six or seven hours. Just before midnight, they gave her another EKG. It looked much better. She was cleared to go home. Her neurologist happened to be on call that weekend and told us to give her no Lamictal for a day, then slowly get back to her 200-milligram dose.
No Tidy Lesson
Tess is doing much better now. She can walk on her own again, back to going up and down stairs.
This is our third trip to the ER with Tess since last August. Seizure, seizure, medication overdose. Hard to believe she’s been through so much. Hard for me to think about the fact that the third time was entirely avoidable and entirely, 100 percent my fault.
I still feel terrible about it. I don’t have a tidy lesson here. No “here’s what I learned” moment. I just wanted to put this out there because I know I’m not the only caregiver who has made a medication error with their child. Research shows that every eight minutes, a child experiences a home medication error. If this has happened to you, know that you’re not alone, and the guilt is real.
The Stronger Every Day podcast is produced by Bo Bigelow, Chairman of the Foundation for Hao-Fountain Syndrome (usp7.org).