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Reporting a Medication Error

Child Resistant Does Not Mean Childproof

dbe05350458c15fa6c802fb686391131 MThe Poison Prevention Act was passed in 1970 to help reduce the number of accidental childhood poisonings. The Act required manufacturers of medicines and household products to develop a package that would make it more difficult for a child, age 5 and younger, to open. Since then, many over-the-counter (OTC) and prescription medicines are sold with a child-resistant cap. However, these caps do not fully prevent a child from opening the medicine – they are NOT childproof. Tragic cases of young children dying or becoming seriously ill after taking medicine from vials or bottles they were able to open occurs even with the use of child-resistant caps. Some examples of recent stories found in the media are listed below.


• This past August, a news report from California indicated that a 5-year-old child died after taking some of his parents’ prescription diabetes medicine. Further details about the incident are not available

• A 20-month-old girl climbed up on a dresser and found her siblings medicine for treating attention deficit disorder (ADD). She opened it and began eating the tablets. Her father found her with the open bottle. She was taken to the hospital in critical condition, but recovered.

• Three-year-old twins climbed onto a kitchen counter and found medicine in a child-resistant prescription bottle stored in a high cabinet. They were able to open it up and both of them took the medicine. A little while later, one of the twins complained of feeling sick. The mother found the opened vial of medicine and both children were taken to the hospital. Unfortunately, one of the twins died.

Even medicine that is prescribed for a child can prove deadly. In 2005, FOX 9 news in Minneapolis reported a tragic story. A 15-month-old child died after drinking the contents of a bottle that contained her heart medicine, Tambocor (flecainide). Since birth, the child's parents had given her three doses each day to slow her racing heart. But in a matter of minutes, the child was able to open the prescription bottle and drink all the medicine. The overdose of what was once lifesaving medicine killed her.

The parents had been visiting a friend. The medicine was in a diaper bag, which was sitting at the mother's feet. After feeding the child, the mother sat her on the floor. She went into the kitchen to get another milk bottle from the refrigerator and was back in no time. But it was long enough for her child to open the bottle of medicine and drink it, even though it had a child-resistant cap. The child was rushed to the hospital, but she could not be saved.

Child-resistant caps do not fully prevent a child from opening the medicine – the caps are NOT childproof. In fact, if the child has the medicine bottle longer than 10 minutes, they probably will be able to open it. You cannot rely on child-resistant caps to protect your children. And it is just not possible to watch children every second. So, other strategies need to be put in place to prevent children from gaining access to medicines.

To protect children from accidental poisonings with medicines:

Buy safety packaging. Buy medicines and vitamins with child-resistant caps or packaging. Replace caps tightly after use. But remember, child resistant doesn't mean childproof. Given enough time, children may be able to open the container.

Keep medicines out of reach. Young children investigate their world by putting most things in their mouths. So store medicines in their original containers in a locked closet, cabinet, or drawer (not in the bathroom), where children cannot see or reach them.

Don't forget vitamins. Vitamins are medicines, too. In fact, vitamins with iron can be especially poisonous to children, so be sure to lock them up.

Secure purses. Keep purses and diaper bags (which may contain medicines) out of reach of children. Be aware of medicines that visitors may bring into your home. Children are curious and may investigate visitors’ bags, purses, and suitcases.

Avoid taking medicine in front of children. Also, don't give a child medicine while another child is watching. Young children learn by imitating adults.

Never call medicine candy. Medicines and candy can look alike and children can’t tell the difference. They may eat and drink anything no matter how bad it tastes.

Alert babysitters. Many poisonings occur when the daily household routine has been disrupted. So alert your babysitter to this risk and what to do to prevent poisonings.

Take the medicine with you. If you are in the process of taking or giving medicine, take it with you to answer the door or phone. Never leave the medicine on the counter.

Teach children. Frequently remind children to never take medicine unless an adult gives it to them. Also teach them that poisons often look like food or drink. Thus, they should ask an adult before eating or drinking anything.

Safely dispose of medicines. Regularly clean out your medicine cabinet. Discard old medicines by taking them to a drug take back location (www.ismp.org/ext/800). If there is not a location near you, mix the medicine with an undesirable substance such as used coffee grinds, dirt, or cat litter in a sealable plastic bag. Then place the sealed bag in your trash. There are some medicines that can be flushed down the toilet. For complete instructions on disposing unused medicines, go to: www.ismp.org/ext/256.

Call the Poison Help line right away. Keep the Poison Help line phone number (1-800-222-1222) near your house phone and program it into your cell phone. If you suspect or know your child has taken a medicine, call immediately. Do not give the child anything to eat or drink, or make the child vomit unless instructed to do so.

Watch for repeat poisonings. Children who have already taken medicine on their own are more likely to try it again.

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