Following through on medicine safety concerns

by Michael R. Cohen, R.Ph.

Published Jul. 16, 2014, 10:27 a.m. ET

The mother of an 8-month-old girl was given a prescription for her baby for amoxicillin 400 mg twice daily. Amoxicillin is an antibiotic commonly used to treat various ear, nose, throat, chest, and skin infections. When dropping off the prescription at the pharmacy, a pharmacist asked the mother for the child's weight, which was 20 pounds. When the mother picked up the medicine, the pharmacist gave her a 5 mL syringe to use to draw up each dose of the liquid medicine. The directions on the prescription said, "Amoxicillin (400 mg/5 mL), give 12 mL twice a day." The pharmacist told the mother to give her child two full syringes of the medicine (5 mL each), and then 2 mL of another syringe of medicine.

After the mother arrived home, she began to prepare a dose for her child. But she thought 12 mL seemed like too much medicine, so she decided to read the consumer leaflet provided by the pharmacy in the bag with the medicine. Unfortunately, she had been given a partial page of a consumer leaflet for three different medicines—one page for amoxicillin, one for ciprofloxacin (another antibiotic), and one for Tradjenta (linagliptin, used to treat diabetes).

Because there was not enough information on the partial page of the leaflet on amoxicillin, the mother decided to call a friend in the medical field, who also felt 12 mL (960 mg) of medicine was too much for a young child. The mother called the pharmacy, and the mistake was uncovered. The child should have received just 5 mL (400 mg) of the medicine for each dose, not 12 mL (960 mg). The mother returned the medicine with the incorrect directions and filled a new prescription for the medicine at another pharmacy.

The mother avoided giving her child too much medicine because she questioned the large volume of medicine needed for each dose. And then she followed through on her concerns. However, I suggest calling a pharmacist, doctor, or nurse with any medication concerns, as a friend without medical training may not recognize an error and instead give you false assurances regarding a true concern.