From the February 2008 issue

Just before Christmas 2007, an 8-month-old girl was prescribed amoxicillin/clavulanate potassium (AUGMENTIN) suspension to treat an ear infection. The prescription was taken to the family’s local community pharmacy where a stock medication bottle labeled with instructions to give the child a half tea-spoonful twice daily by mouth was dispensed. When the family arrived home, they measured a half teaspoonful of the powder and administered it to the girl. The pharmacy had failed to mix the powder prior to dispensing the medication. The girl was rushed to the emergency department where she was treated for the antibiotic overdose.

In February 2007, we reported a similar event in which a young boy received 9 g of amoxicillin, instead of 450 mg, when a community pharmacy failed to mix his antibiotic. Given the recent event, reviewing strategies to prevent these errors is WorthRepeating…

• Consider placing new prescriptions for oral liquid medications, especially those that need to be reconstituted, in a separate area away from other prescriptions waiting to be picked up. Mark the area as “not to be dispensed without speaking to the pharmacist.” This may help remind staff that the product must be mixed prior to dispensing and that a pharmacist should review directions for use with the patient or caregiver.
• Include specific product descriptions on the prescription label (e.g., orange-flavored, white, opaque liquid).
• Review the label, route of administration, and directions for use with the patient. Open the bottle with the patient and/or caregiver.
• Ensure that oral syringes (without caps) or other appropriate measuring devices are provided with the product or are available for purchase at your practice site.
• Provide education to patients and caregivers regarding proper use of the measuring device.
• Have the caregiver or patient demonstrate how to measure and administer the dose to validate learning.
• Show caregivers how to clean the device.