When I was a college student in 1981, tests showed I had a genetic adrenal insufficiency. My doctor prescribed a daily dose of half a milligram of Dexamethasone. I stayed on that dosage for nearly twenty years. In 2001, I was a highly successful international mergers and acquisitions lawyer, the owner of my own technology consulting practice, an athlete, Episcopal priest and mother of two small children, Rachael and Charlie.
At the pinnacle of my career, Dr. Timothy Evans, the general practitioner to Britain’s royal family, wrote me a correct prescription for .5 milligrams of Dexamethasone in June of 2001. In July of 2001, he inadvertently changed the routine prescription to read four milligrams—that amount constitutes a lethal dose when taken for an extended duration. He set up a catastrophic chain of events.
The following month, a US doctor conducted my annual physical. Because the effects of Dexamethasone are cumulative, although my American doctors ran tests for a complete physical (those tests were within weeks after I began the daily, lethal dose of Dexamethasone) my physical indicated nothing was wrong.
Relying on the label contained on the medicine bottle that reflected Evans’ incorrectly prescribed dose of 4 milligrams, the US doctor refilled the same poisonous dose for three further months.
I remained unaware of the increased medication for nearly four months. Weakness, dizziness, anxiety, and mental confusion plagued me, but I never suspected the medication. When mother planned to visit from Cleveland, I emailed my American doctor and asked him to refill the prescription of Dexamethasone for half a milligram.
“I prescribed four milligrams,” he wrote in a return email. “Check the label on your prescription at once.”
I checked the label on the bottle in my bathroom. He was correct and I was terrified. I looked into the mirror and saw my moon shaped face, thin hair, and bulging black rimmed eyes.
Because I am a runner and my mental and physical health were so strong, it took far longer for me to be brought down by the overdose than it would have for an average person.
Under medical advice, I tapered down from the lethal dose. Little did I know that the tapering process often triggers a hideous form of steroid psychosis. I suffered a complete mental and physical breakdown and my body was riddled with a psychosis that took years from which to recover.
In 2007, at the suggestion of the World Health Organization’s head of Patient Safety, I founded FLAAME (Families Launching Action Against Medication Errors). I later asked Kelly Jerry to join me as a co-founder. We have testified in the House and Senate on legislation to prevent medication errors.
FLAAME’s purpose is to eliminate prescription errors, medication errors, and negative drug interactions. Medication errors are conservatively estimated to account for more than 7,000 deaths annually—more people than have died in the Iraq war. The US Pharmacist Journal (a peer-read journal) estimates that in the life of a pharmacist who is 99 percent accurate, he/she will fill an average of 490,000 prescriptions, and likely kill six people.
I often speak publicly around the US in the area of medication safety. I have a literary agent and am writing a book with Cecil Murphey with the working title of Lethal Dose. The book details my struggle to overcome the traumatic effects of the senseless medication error that nearly cost me my life. I will tell you more as the project develops.