Thread: Drug Errors
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Old 20th, July 2006, 10:25 PM
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Quote:
Originally Posted by admin
A couple of weeks ago a parent came into the pharmacy and told me two days previously her child had been prescribed paracetamol and amoxicillin. She had put the penicillin in the fridge. The top on the penicillin was not a child resistant cap, and the child had gone into the fridge and drank the whole bottle.

This had led to a few hours in the local A @ E department, and a child with diarrhoea and vomiting for the night.

The penicillin did not come with a CRC and unfortnately the original cap was used, which enabled the child to open the bottle and drink the contents. Obviously if this had been the paracetamol the consequences could have been a lot more serious.

I alerted the pharmacist who had been on duty that day, and used the correct error reporting procedures for the store.
Unfortunately the result is likely to be
A) The SOP already states that CRC caps should be used
B) the above will be added to the SOP

Reporting directly to the Patient Safety lot might put pressure on the store to purchase (and manufacturers to market) liquid antibiotics with CRC's as standard.

Jeff
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