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Reporting a Medication Error

Great catch with newborn’s medicine

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After nearly 2 weeks in a neonatal intensive care unit, a newborn baby was discharged to home with a prescription for liquid phenobarbital (20 mg per 5 mL) twice a day to prevent seizures. Before leaving the hospital, the baby’s doctor reviewed the prescription with the parents. He made sure the parents knew the baby’s dose (6.5 mg) and how much of the liquid medicine to give the baby for each dose (1.6 mL).

When the baby’s father brought the medicine home from the pharmacy, he noticed that the label on the bottle said, “Phenobarbital 20 mg/5 mL, give 6.5 mL twice a day.” He became concerned because he remembered the doctor telling him the baby’s dose was 6.5 mg, and the amount of medicine for each dose would be 1.6 mL. He called the pharmacy and asked for a copy of the prescription the doctor had sent electronically to the pharmacy. When he received it, he noticed that the baby’s year of birth was incorrectly listed as 1985. Thus, he presumed the pharmacist had thought the phenobarbital was for an adult, not a 2-week-old baby.

The father then emailed a picture of the label on the prescription bottle to the doctor. The doctor agreed that the pharmacy had made an error. He confirmed that the baby’s dose was 6.5 mg, and that each twice-daily dose required 1.6 mL of the liquid medicine.

Community pharmacies typically make very few errors when dispensing the billions of medications prescribed annually. However, when errors are made, mistaking the mg dose for the mL volume of a liquid medicine is a fairly common mistake. Five mg becomes 5 mL, 10 mg becomes 10 mL, and in this case, 6.5 mg became 6.5 mL. These errors can be serious, especially for young babies. In this case, had the father given his baby 6.5 mL, it would have resulted in a dose of 26 mg, not the prescribed dose of 6.5 mg. This 4-fold overdose could have caused the baby to slow or stop breathing.

Here’s what you can do: This great catch is an example of why it is so important to make sure you understand all the discharge medicines prescribed for you or your loved one. In this case, the doctor reviewed the phenobarbital prescription with the parents prior to discharge, and the father was able to remember these instructions. But it is safest to make sure the prescription details are on the discharge paperwork, so you don’t have to rely on memory of the verbal instructions. Also keep in mind, had the father talked to the pharmacist when he picked up the filled prescription, the error would likely have been caught in the pharmacy before going home. Always ask to talk to the pharmacist, especially when picking up filled prescriptions for new medicines.

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