State Health Officials Find All but 16 Mislabeled Pills

State health officials, trying to track down mislabeled prescription pills that put a Buena Park woman into a coma earlier this week, said Friday that they can account for all but 16 of the tablets.

Ray Wilson of the state Department of Health Services said the 16-tablet discrepancy was found in the records at Medical Mart Med-Pak of Costa Mesa, a small firm that buys prescription drugs in bulk and repackages them in small containers for dispensing by clinics and doctors’ offices.

Health officials issued an alert Thursday for patients at AmeriCare 1 clinics in La Palma and Orange, warning them that they might have been given mislabeled Med-Pak containers with potentially deadly pills inside. On Friday, Wilson said all the mislabeled pills dispensed by those clinics had been located or recovered. A Med-Pak spokesman said 19 mislabeled vials had been distributed.

Woman Fell Into Coma

The mix-up came to light when a Buena Park woman in a coma was taken to Mullikin Medical Center in Artesia. At the AmeriCare 1 clinic in La Palma, she had been given a box of Med-Pak pills labeled “metronidazole 250 mg”--a drug used most commonly to combat vaginal yeast infections. The box instead contained tolazamide, an anti-diabetic drug that can cause low blood sugar, coma and death when taken in doses recommended on the metronidazole label.

A spokeswoman for Mullikin Medical Center said the woman, whose name was not disclosed, was released from the hospital Friday.

Wilson said state investigators are “fairly comfortable” about the 16-tablet discrepancy, although they will continue their search today. He said Med-Pak had received two 1,000-tablet jars of tolazamide and that being unable to account for as few as 16 is not particularly remarkable.

“The bottles are supposed to have 2,000 tablets,” Wilson said, “but they may have had 1,998 or 2,001. There is variability there. In some of the (Med-Pak) vials we have found, there were a couple of extra tablets, even in those small quantities.”

No Further Reports

(Med-Pak vials contain 8, 21 or 30 tablets each, a company spokesman said.)

“We’re fairly comfortable with (a discrepancy of) 16,” Wilson said. “We’d like to be able to get it closer.”

He said he has received no further reports of patients taking the mislabeled pills.

Steve Morton, vice president of Med-Pak, said his firm had shut down operations while health officials searched through their records. He said Med-Pak is investigating the mix-up as well and “that investigation will include a complete review of all records, procedures, personnel and inventory to determine if the bulk drugs were delivered to our plant properly labeled.”

Morton said Med-Pak has been in business for “about a year,” first occupying part of a small industrial park in Costa Mesa but now in the process of moving to Huntington Beach.

He said the firm has four employees, three of whom actually do the drug repackaging work. All have “exemptee” status with the state Department of Health Services, meaning they have passed tests and been granted licenses by that department.

Wilson said the firm has 15 customers.