How Parents Can Protect Their Children from Pharmacy Errors

Medical professionals have a duty to patientsA Colorado family is warning parents across the nation to be cautious of pharmacy errors after losing their 8-year-old son. The parents have spoken to national press outlets about how a pharmacy error caused the death of their child.

According to the parents, the boy had been prescribed Clonidine to treat ADHD. Clonidine is a sedative used to treat high blood pressure in adults and ADHD in children.

The boy had taken Clonidine for three years with no issues, until the local pharmacist accidently administered 1000 times the prescribed dose. It turns out the pharmacist had made this mistake more than once. The first time the pharmacist made this mistake, the child was only hospitalized with brain swelling, which is still very serious, but not always fatal. However, after the pharmacist made the mistake again, the boy lost his life.

Although it appears this case involved a liquid solution of clonidine, making it more difficult to detect an error, there are ways parents can protect their children from succumbing to similar mistakes.

Communication and Diligence Can Prevent Pharmacy Errors

Preventing pharmacy errors requires constant communication with health care providers and diligence. Parents can also use certain tools to double-check for errors.

Medication reconciliation: According to the Mayo Clinic, medication reconciliation can reduce the chances of prescription errors made during transitions in care (switching doctors, hospitals or health care providers). Medication reconciliation involves making an accurate listing of all prescription drugs and supplements a patient is taking, and comparing that list with admission, transfer and discharge orders. This process might prevent dosing errors and harmful drug interactions.

Communication/asking questions: Communication is essential for preventing pharmacy errors. Some drug names are similar or come in identical looking containers (such as ear drops and eye drops). Parents can also ask pharmacists or health care providers to double-check dosages.

Verify medications online: Parents can use the National Library of Medicine’s website, www.pillbox.nlm.nih.gov to view photos and other information involving prescription medications. Medications have different appearances based on dosages. This database might allow parents to double-check prescription medications, verify dosages and create questions to ask health care professionals. All medical information obtained online should always be verified by a physician.


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