REDUCING MEDICAL ERRORS

A five year old boy was rushed to Saint Elsewhere Medical Center ER after he was found unconscious at home. He had been diagnosed to have ADHD and taking a stimulant amphetamine/dextroamphetamine and clonidine. On the day of hospitalization the parents refilled the clonidine which was labeled 0.05 mg/5ml with an instruction to take one teaspoon at night. The child received the first dose from this bottle at night and 20 minutes later he was found limp and unresponsive.

The father tasted the content of the newly refilled clonidine suspension and within 20 minutes he felt dizzy.

He was admitted to the pediatric intensive care unit (PICU) and he was intubated to assist his breathing. He was given atropin and naloxone intravenously and other supportive measures were done at the PICU. After 42 hours of hospitalization he was sent home back to his normal state.

A serum level of clonidine was done and it was 64.0 ng/ml. This is the highest ever reported level of clonidine in a child.

The error in this case was wrong compounding of the clonidine at the pharmacy that resulted to a 1000-fold error in drug compounding.

There has been four reports of deaths from clonidine overdose as an acute single drug ingestion. A three year old girl who accidentally took 20 to 30 tables, a 23 month old girl who ingested an unknown amount, and two adults ingested unknown amount in a suicide act.

Reference: PEDIATRICS, August 2001, page 471

[Comment: If possible compounding of medications at a pharmacy should be avoided if there is a possibility of mistake resulting to 10-fold error in dose volume. Most children with ADHD can take tablets.]

Example of Diagnostic Error   False Positive Biopsy   Prescription Error   Systems Errors   Flying Infusion Pump   Printed Prescription   Medical Errors a National Problem   Compunding Medication Error   Pediatric Surgery Errors

Leo Leonidas, MD, FAAP, Assistant Clinical Professor in Pediatrics, Tufts University School of Medicine, Boston; Attending Pediatrician, Eastern Maine Medical Center, Bangor, Maine.