Toddler receives antidepressants instead of antibiotics. How to stop a similar mistake
Key Takeaways
In a medication mix-up, a 3-year-old received antidepressants instead of antibiotics.
Medication dispensing errors like this are common and preventable sources of patient harm in healthcare.
To avoid these errors, doctors and other healthcare professionals involved in handling or dispensing medications should work diligently and collaboratively to ensure patient safety.
In a recent medication mix-up in California, a 3-year-old received antidepressants instead of antibiotics.[] The patient’s mother told reporters that she was “shocked and kind of scared” to discover the error after picking up the medication at a local Rite Aid. Luckily, she realized the error before her daughter consumed the medication.
“If I had not read that and just given it to her it would’ve been really bad,” the mother told 23ABC. She added that the situation was “odd and concerning because there are a lot of steps you are supposed to take before you hand out a medication to someone from a pharmacy.”
The incorrect medication that she picked up was Trazodone—a medication used mainly to treat depression and insomnia—which had been prescribed to another man, the mother said.
While it is fortunate that the mother caught the medication error before administering the drug to her daughter, not all patients are so lucky. Alarmingly, reports state that “[m]edication dispensing errors rank as the most frequent and avoidable source of patient harm,” including injury and death.[]These errors can occur at multiple points, from writing the prescription to administering the drug.
As doctors, you have your patients’ best interests at heart and know the importance of giving them a safe and accurate drug experience. You may also know that committing a medication error may result in legal repercussions, including facing civil legal actions or criminal charges. Within your practice, you could undergo disciplinary action or lose your patients’ trust.
For everyone’s benefit, it is important to do your best to avoid medication errors. You can start by making sure that you are aware of all the steps in the drug process and keep an eye out for errors so that you can catch them before a drug potentially causes harm to a patient.
Some steps include:
Ordering and prescribing
Documenting and transcribing information related to the prescription
Dispensing the medication
Administering the medication
Monitoring the patient’s use of and interactions with the medication
Researchers say that nearly half of all medication errors occur during the prescribing, ordering, and administration steps.
Still, the above steps shouldn’t fall to you alone, as physicians, pharmacists, and other healthcare professionals can be involved in drug discussions and delivery. As such, it is important that you work collaboratively with pharmacists and other healthcare professionals to ensure medication safety and accuracy.[] This can mean facilitating timely and accurate handoffs of information to the next person in charge of handling the patient’s prescription. This can also mean facilitating clear and open communication with the patient, who remains your constant priority despite a fragmented healthcare system.
What this means for you
Medication dispensing errors are frequent and preventable causes of patient harm in healthcare. To avoid these errors, doctors should diligently attend to the drug prescription and administration process and work collaboratively with pharmacists or other healthcare providers to facilitate accurate handoffs of information.