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Pharmacy gave our baby wrong dosage

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  • 15-08-2021 6:52pm
    #1
    Registered Users Posts: 2,804 ✭✭✭


    So our baby was on course of antibiotics that was supposed to last 7 days. Only problem was we got half way through and have run out already. Called pharmacy. Went in. After seeing the bottle dispensed I get told we were giving our baby double the dose each interval. They had given wrong dosage on bottle.

    Majorly pissed off. I was told sure it wouldn't do any harm. Give him probiotics...

    Any experiences ? First time this has ever happened.



Comments

  • Registered Users Posts: 235 ✭✭LapsypaCork


    I hope you kept the bottle, was it countersigned before being dispensed. Have you contacted your GP to inform them of the error and also that you gave the medication in double doses? I would also be requesting that the GP record this. This was not ok despite what the pharmacy have said, would it be ok of it were other medications which could have had very serious implications? Contact your GP ASAP and keep record of everything, write a formal complaint to the pharmacy manager, they should respond with an apology, if you don’t get anywhere you can always send a formal complaint to the Pharmacy Regulator



  • Registered Users Posts: 7,515 ✭✭✭the_pen_turner


    while you were lucky this time there was no harm don eit could have been a lot worse and killed the child.

    not sure who to report it to but it should be



  • Registered Users Posts: 3,063 ✭✭✭xhomelezz




  • Registered Users Posts: 3,063 ✭✭✭xhomelezz


    Contact your GP just to make sure no harm was done.



  • Registered Users Posts: 991 ✭✭✭cubatahavana



    Supervising pharmacist here. While this error should not have happened, to suggest that a dispensing error could’ve killed the baby is preposterous. Very few antibiotics would have a harmful effect on a baby, even if given at double the dose prescribed.

    More than likely it was amoxicillin, which anyway prescribers usually under dose. We’re you giving the baby 10mls? That would’ve been 500 mg in the worst of cases (if the bottle was the 250 mg/5ml) and that dose is fine for any kid weighting over 16kg. If it was the 125mg/5ml bottle, you would’ve been giving him 250 mg, suitable for an 8 kg baby.

    Having said this, it was a dispensing error and it shouldn’t have happened. If you feel that the pharmacist was dismissive when you brought the error to their attention, you can contact the superintendent pharmacist. All errors must be logged and the GP has to be informed of it by the pharmacist, so make sure that that has happened.


    feel free to PM me if you have any queries about the antibiotic and the dose



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  • Registered Users Posts: 7,515 ✭✭✭the_pen_turner


    how is it preposterous. this time it was ok . your post shows that the over dose was no harm . im not disputing that.

    but at the end of the day the pharmacist gave out the wrong medication than what was perscribed. the pharmacist could have very easily given the wrong type of medication instead of the wrong amount.

    it happened to me . im elergic to penacillen and the pharmasist gave me something with it in it. luckely i showed them to my mother before i started taking them and she realised. it was after the dentist and i had told them about the penacillen and he perscribed something diferent



  • Registered Users Posts: 991 ✭✭✭cubatahavana


    Dispensing errors in Irish community pharmacy are rare (0.035% rate in an unpublished study). Dispensing errors that cause harm (not death) are even rarer, with very few deaths due to them (only one that I am aware of). It is not “very easy” to dispense the wrong medication. While I agree that the dispensing error happened and that all of them need to be taken seriously, recorded and discussed with the team as a learning experience; it is impossible not to have dispensing errors in a pharmacy. Same with GPs with prescribing errors and any other profession. No one is perfect. The main thing is that errors are used as learning experiences for them not to happen again.

    Of course, a dispensing error occurring on a baby is way more worrisome for the parents. Speak with the manager/superintendent if you’re not happy with the explanation given to you.



  • Registered Users Posts: 235 ✭✭LapsypaCork


    Have to take these things seriously and record the events, while it did no harm and the patient is ok, the pharmacists reaction was a bit fazed IMO and if the issue is dealt with in a professional way, it is potentially preventing a more serious incident in the future.



  • Registered Users Posts: 2,804 ✭✭✭Xcellor


    The anti b was phenoxymethylpenicillin calcium.

    I know mistakes happen but damn scary when it happens to your baby.



  • Registered Users Posts: 3,063 ✭✭✭xhomelezz




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  • Registered Users Posts: 991 ✭✭✭cubatahavana


    It’s a penicillin antibiotic, more than likely absolutely fine, but diarrhoea could be a side effect of giving the baby a higher dose. Very rarely there would be something more serious.

    I agree with you that giving the wrong dose to a baby is frightening. Speak with the manager/superintendent.



  • Registered Users Posts: 235 ✭✭LapsypaCork




  • Registered Users Posts: 2,804 ✭✭✭Xcellor


    Yes well I gave the pharmacist my number and asked for call back from the supervising pharmacist. In fairness she was transparent and made it clear the mistake had been made. I wouldn't have known - I just assumed there wasn't enough mixed... But even that was pointing to a dispensing problem. She dispensed more with the correct instructions to finish the course if we felt it was needed. Given that he has in fact had the original course albeit in a more condensed format we may leave it...



  • Registered Users Posts: 991 ✭✭✭cubatahavana


    There are many professionals now aiming to change guidelines for antibiotics for children. Instead of taking the full course they recommend to take it while the kid is sick. If he/she has recovered, I don’t see the need in continuing to treat



  • Registered Users Posts: 798 ✭✭✭Yyhhuuu


    You say it is "impossible not to have dispensing errors in a pharmacy" well why are dispensed prescription only medications not double - checked as they are in the U.K. and as they are by two nurses in Irish hospitals prior to dispensing to patients?. If they are double checked at community Pharmacies then how is a dispensing error possible ( unless it was merely a tick- box exercise without being actually double checked?) Furthermore I find your use of the word " propesterous" in dismissing a legitimate concern regarding the child very unhelpful. You should also be mindful that paediatric overdosing can have serious consequences. You would say dispensing errors are rare in Irish Pharmacies wouldn't you being a Pharmacist. Many dispensing errors would be either: 1. Unidentified ; or 2. unreported so I'd take your low figures with a large pinch of salt.

    I would suggest the OP draw the matter to the attention of the Pharmaceutical Society of Ireland and the child's gp or Physician asap.


    I must say most Pharmacist's I dealt with were the utmost professional to deal with and I do understand how human error can occur but surely if the prescription is double checked this risk is virtually eliminated.

    Pharmacists charge far too much in this country if you ask me. Many are on huge six- figure salaries. I would advise anybody to shop around for private prescriptions as like insurance there are large price differences.



  • Registered Users Posts: 991 ✭✭✭cubatahavana


    1- prescriptions are dispensed double checked in almost all pharmacies. Still, errors can happen. The rate of errors in Ireland is similar to other countries. That is about 3 errors per 10000 items dispensed.


    2- errors in hospitals are far more common, with some studies showing up to 250k preventable deaths happening in US hospitals per year (Even though some studies say that that number should be as low as 22k)

    https://news.yale.edu/2020/01/28/estimates-preventable-hospital-deaths-are-too-high-new-study-shows

    3-what I find preposterous is the claim from the poster saying that the mistake could’ve easily killed the baby

    4- dispensing errors have to be taken seriously and every pharmacist that I know does

    5- after nearly 20 years working in Ireland, I don’t know of any employee pharmacist making 6 figures as you declare. By all means people can shop around, but in the pharmacy profession, not all is price differences. The relationship with your local pharmacist is very important, as it is your trust in him/her.

    6- pharmacists are the most trusted professionals in Ireland. The problem is that if the GP or prescriber makes a mistake, this is usually spotted by the pharmacist, but as we are the last link on the chain, our mistakes reach the patient.

    https://www.ipsos.com/sites/default/files/ct/news/documents/2021-03/veracity_index_2021_2.pdf



  • Registered Users Posts: 40,457 ✭✭✭✭ohnonotgmail


    just on the question of double checking @cubatahavana, who is doing the double checking? I've rarely seen two pharmacists on duty in my local pharmacy so who is doing the second check?



  • Registered Users Posts: 4,713 ✭✭✭BabysCoffee


    I would imagine a pharmacists assistant does the second check?



  • Registered Users Posts: 40,457 ✭✭✭✭ohnonotgmail


    right, but how much are they actually capable of checking? there must be a limit to how much they can check.



  • Registered Users Posts: 2,045 ✭✭✭silver2020


    Jaysus - Catastrophe syndrome. It was a higher dose of an anti-biotic. f the op has concerns they contact the GP not put it on a forum so that the scaremongering snowflakes can come up with ridiculous theories.



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  • Registered Users Posts: 991 ✭✭✭cubatahavana


    Tech prepares and checks the medication and pharmacist double checks it



  • Registered Users Posts: 991 ✭✭✭cubatahavana


    Most pharmacies would have one pharmacist for every 100-150 items dispensed per day. If there are more than 200/day, there usually is a double cover. So if we go with 150 items per day, a pharmacist would check an average of 15/hour or so. Having said this, this is not the only job that he/she does. And there are busier times when there are more than 20-30 per hour. The pharmacist has to check not only that the item dispensed is the prescribed one, but that it is appropriate for the patient in terms of strength, dose, frequency and so on; that it doesn’t interact with other medicines that the patient may be taking; that the patient knows how to take it; and so on



  • Registered Users Posts: 40,457 ✭✭✭✭ohnonotgmail


    My local pharmacy must be an outlier so. Only ever 1 pharmacist on duty. I know this because I know the staff personally. And it is busy. Very busy.



  • Registered Users Posts: 2,804 ✭✭✭Xcellor


    Already spoke to Doctor today and supervising pharmacist. The doctor was quite concerned and asked details of babies weight and that further antibiotics were dispensed given that he had already been given more than he needed.



  • Registered Users Posts: 7,515 ✭✭✭the_pen_turner


    as i said , lucky this tiem. but you cannot say that it could go wrong and kill someone. its not scarmongering



  • Registered Users Posts: 2,988 ✭✭✭gipi


    A friend of mine received incorrect epilepsy medication from a pharmacist over the course of a 12 month period - should have received slow-release meds, was given the regular-release meds (drugs had the same name, so wasn't spotted by either pharmacist or friend). It meant that for most of that year, she wasn't properly medicated.

    During those 12 months, she collapsed on the street twice (taken to hospital both times), was absent from work several times due to feeling ill (and not knowing why), and, scariest of all, went missing one evening - she was so confused, she got off a train at the wrong stop, and wandered around for over 2 hours not knowing where she was, and unable to formulate her thoughts to make a phone call. Gardaí eventually found her (safe and well, but confused).

    When the hospital finally worked out the reason for all the incidents, she went back to her pharmacist, who shrugged their shoulders and said nothing. It took the woman a couple of years to get her confidence back, she was afraid to go outside the door in case she had another strange episode.

    Not quite "catastrophe syndrome", but scary nevertheless. I can only imagine how scary it feels for parents of a baby who realise they've given the baby too much medication. Hope baba is doing well now, OP.



  • Registered Users Posts: 991 ✭✭✭cubatahavana


    This is a case that needs to be investigated further. Was the epilepsy meds prescribed as immediate release? If it caused harm to the patient and the pharmacist “shrugged it” and no more explanation was given, your friend should contact the pharmacy regulator.



  • Registered Users Posts: 991 ✭✭✭cubatahavana


    They were definitely not lucky, as they got the wrong dose. To imply that they were lucky that the baby did not die is again, scaremongering.



  • Registered Users Posts: 991 ✭✭✭cubatahavana


    Good that you spoke with them. Hope that they were able to answer your doubts and worries and I hope that your baby is fine. As a health professional, I always worry when a dispensing error happens



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  • Registered Users Posts: 1,229 ✭✭✭mvl


    well, what happened to my baby many years ago was for the pharmacist to dispense the wrong antibiotic. really. realized after first tries giving it to my child that it had an unusual smell - so opened the guidelines : it was a urinary tract infection antibiotic, instead a respiratory one... brought it back - the pharmacist was so embarrassed while apologizing (good thing then was that my baby didn't like taking medicine at the time, so barely got some) ... this experience made me more cautious, started to doublecheck everything baby related, and I also stopped going to that pharmacy for prescriptions (do get cosmetics from them on occasion).



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