A medication mix-up at a Klein ISD elementary school has raised serious questions after a mother tells KPRC 2 her twin boys’ prescription ADHD medication disappeared just days after she delivered a fresh, 30-day supply.
During a routine audit on Monday, the pill bottles were found to contain similar-looking over-the-counter medications instead, according to a letter to families shared with KPRC 2.
The school district confirms that an investigation is underway involving the Klein ISD Police Department and other agencies being notified.
“I wouldn’t have given it to the school kind of hodgepodge like that,” Kuehnle Elementary School parent Courtney Griffin said, noting that some of the over-the-counter pills were irregularly split, and not all in half, the way she would have done it for her child. “I’m really careful about it.”
As a mother and nurse, she has trusted the school to administer her children’s ADHD medication during lunchtime for years.
Her 10-year-old twin boys receive prescription dexmethylphenidate, the generic version of Focalin, for their ADHD around noon every day, she said.
During the routine audit, the school informed her that one of her sons had a bottle full of Aleve, while the other had a bottle that contained loratadine, an over-the-counter allergy medicine.
“These are controlled substances, like this is a big deal. These things have street value,” Griffin said.
She had provided the school with a fresh 30-day supply just last Monday, but now all those pills are missing.
“While the medication was secured correctly in the clinic, required intake procedures were not followed when the medication was delivered to the campus by the parent,” Klein ISD wrote in a letter to families after being contacted by KPRC 2 on Tuesday.
The district added that it cannot “confirm whether the incorrect over-the-counter pills were present at the time they were submitted.”
“You have to make sure what you’re giving is what is prescribed. And that didn’t happen,” Griffin said. “Just because it’s in a school setting and not a hospital setting doesn’t make it any less important.”
One son’s bottle should have had blue pills with an A1 on them while the other with white pills split in half with an A3 on them.
The replacement pills look strikingly similar: One bottle had blue pills with L490 on them, and the other had white pills split in half with an unclear letter and number combination.
“The way it was done so efficiently, I’m afraid that my kids aren’t the only ones that this has happened to,” Griffin said.
Klein’s Director of Health Services Dr. Yvonne Clark insisted in the letter that “all other prescribed oral medications for all other students correctly match.”
At first, Griffin thought it was just a human error when she heard about the first son, before receiving another call 45 minutes later, she said, indicating her other son’s pill discrepancy.
“It’s a coincidence, but at a certain point, it’s just not a coincidence anymore,” she said.
It’s less of a coincidence because she noted that the same thing happened last year.
“Nobody’s that unlucky,” she said, adding that the school has tried to suggest the pharmacy possibly made a mistake.
Griffin’s son, when asked, believed he had taken the correct pill.
“As a matter of fact, I asked my son … He thought he took the correct pill,” she said, but she did receive a call Friday that one of her sons had been acting up in class, which said is expected if he doesn’t take his medication.
She doesn’t know how long her boys may have been given something else.
Griffin hopes the school takes the situation seriously and conducts a thorough investigation into who is handling the medications internally.
“We were lucky. My kids were fine. We were lucky that they didn’t have an issue with the medicines that they got,” Griffin said.
In response to the incident, Klein ISD has announced that school staff will undergo retraining on medicine intake procedures. The district will also require a pill identification check at delivery time by both the school nurse and the parents, according to the letter.
Read the full letter from Klein ISD:
Dear Kuehnle Families,
I want to share important information regarding a scheduled medication audit that recently took place for our Kuehnle clinic as part of our ongoing commitment to student safety.
Klein ISD has strict protocols in place to ensure that students receive the correct medication while at school. During the most recent routine medication audit, a discrepancy was discovered in the medication provided for two students from the same family. When this was discovered, we immediately contacted the students’ parent and shared that while the medication was secured correctly in the clinic, required intake procedures were not followed when the medication was delivered to the campus by the parent. Because this step was missed, we cannot confirm whether the incorrect over-the-counter pills were present at the time they were submitted by the parent.
Thankfully, the children involved were unharmed by the over-the-counter medication in the prescription bottle provided by the family. We have carefully checked and can confirm that all other prescribed oral medications for all other students correctly match the prescribed medication and are appropriately secured in the clinic.
This matter is under investigation, is being reported to the appropriate agencies, and we have taken immediate corrective action, including:
- Re-training all relevant staff on intake verification procedures
- Requiring pill identification checks at the time of delivery by both the parent/guardian and the school nurse
- Increasing the frequency of medication audits throughout the school day
If you have any questions, please contact the School Health Services Team at (832) 249-4336. We appreciate your trust in our school health teams and remain committed to protecting the health and safety of every student in our care.
Sincerely,
Dr. Yvonne Clarke, Director of Health Services, Klein ISD