Case 1 | A 3-year-old boy underwent an oculoplastic surgical procedure and was discharged home with a prescription for oxycodone for pain control. The prescription included the patient's name and weight, the medication name and volume (1 ml), and frequency. The prescription was filled at an outside community pharmacy. After receiving his first dose, the child was noted by the family to be lethargic and was brought to the ED. Further investigation revealed the patient had received a 20-fold oxycodone overdose, as the 20 mg/ml concentration was dispensed by the outside pharmacy, while the 1 mg/ml concentration was intended, according to the written prescription. |
Contributing negative factors | Child relied on parents for care; pharmacist failed to recognise different concentrations for oxycodone; the amount (mg) was not specified on the prescription; the pharmacist did not double-check the preferred concentration with the prescribing physician; the pharmacist did not have any specific paediatric training; lack of a computerised drug-ordering system connected electronically to outpatient pharmacies; polices (mg/kg/dose) to write drug amounts were not followed. |
Contributing positive factors | Parents were attentive to medication side effects; the pharmacy follows a protocol for medication dispensing. |
How will you reduce the likelihood of this defect happening again? | Require that paediatric prescription pads include dosing such as concentration (mg/ml) and amount (mg/kg). Incorporate paediatric dosing checks into outpatient pharmacy computer systems to alert the pharmacist to overdoses. Educate providers on dosing concentrations. |
Case 2 | Child was prescribed ceftriaxone for IM administration in ED. Prior to medication arrival from pharmacy, an intravenous was placed, and the MD asked nurse to give medication intravenously. Nursing noticed that IM preparation contained lidocaine and did not administer medication intravenous (near-miss). |
Contributing negative factors | Computer order entry did not specify that IM ceftriaxone contained lidocaine. Providers were not aware that IM ceftriaxone included lidocaine. |
Contributing positive factors | Nurse recognised that ceftriaxone contained lidocaine. |
How will you reduce the likelihood of this defect happening again? | Make it impossible to administer IM medications through the intravenous route by incompatible intravenous attachments. Revise computer order entry to indicate that lidocaine is present in IM ceftriaxone. |
Case 3 | A 16-year-old female presented with symptoms of flu to the ED. She was prescribed oseltamivir 75 mg (suspension) by mouth twice a day. The prescription was filled that day at an outside community pharmacy. The mother called back to the ED the next day and said her daughter was very nauseous and not tolerating the medicine, and she was asked to return. Upon return, it was discovered that the daughter was being given 1¼ tsp of concentrated powder (an overdose), as the preparation had not been reconstituted with water. |
Contributing negative factors | It was not clear to the patient or parent that oseltamivir was to be a liquid. Computer system should have alerted pharmacist to reconstitute medicine prior to dispensing. Pharmacist was inexperienced with a large workload. |
Contributing positive factors | Mother recognised that child did not seem to be responding appropriately to medication. There are existing instructions describing the process of reconstituting oseltamivir powder. |
How will you reduce the likelihood of this defect happening again? | Physicians could better educate patients about the dose, route and form of newly prescribed medications. Physician could follow up with patient to ensure prescription filled appropriately and clinical status improving. Educate pharmacists on the need to reconstitute oseltamivir powder prior to dispensing. |
ED, Emergency Department; IM, intramuscular.