Medical Professionals Reference (MPR)Dosing Error Goes Unrecognized Leading to Serious Patient Harm

Pharmacist found 2% liable after patient awarded $40 million for Stevens-Johnson syndrome caused by incorrectly titrated lamotrigine—nurse practitioner doubled manufacturer’s recommended dose, pharmacist filled prescription twice without questioning obvious deviation from boxed warning protocol. Patient permanently lost fingernails, toenails, hair, and vision after ICU admission just 29 days into treatment that should have followed 5-week titration schedule.

⚖️ PROFESSIONAL IMPACT

• Pharmacist held liable despite being last in chain of errors—court rejected attempt to assign full $40 million judgment, limiting liability to $800,000 (2% apportionment) but establishing dispensing duty independent of prescriber actions
• Boxed warning medications trigger heightened verification duty—failure to question dosing that doubled manufacturer’s protocol during titration period deemed breach of standard regardless of prescriber authority or clinic employment structure
• “Last person to see patient” doctrine applied—pharmacist’s position as final safety checkpoint before patient self-administration created independent obligation to counsel and verify, separate from prescriber’s malpractice
• Multiple settlement opportunities eliminated but liability persisted—supervising physician dismissed, clinic dismissed, employer settled, yet pharmacist remained exposed through basic dispensing failures across two separate prescription fills

🎯 ACTION ITEMS

• Flag all boxed warning medications for mandatory titration schedule verification before dispensing
• Document prescriber contact attempts when dosing deviates from manufacturer protocols—dated notes protect against liability
• Counsel every patient receiving boxed warning drugs on specific adverse effects regardless of time constraints
• Establish clinic protocol requiring supervising physician review of controlled substance and boxed warning prescriptions by mid-level providers

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