Focus on local and national incidents to enhance shared learning
🚨 Recent CD Oral Liquid Incidents:
Morphine Oral Solution Incident:
Babies treated for overdose after being given 10mg/5ml instead of the prescribed 100 micrograms/ml.
The 100 micrograms/ml solution is classified as a 'RED DRUG – HOSPITAL ONLY DRUG' available as a 'specials' product.
Refer to the July 2023 alert on cdreporting.co.uk (Resource #107) for more details.
Clobazam Suspension Incident:
Label correctly indicated Clobazam 5mg/5ml but 10mg/5ml was dispensed due to a selection error.
Child received double the intended dose; error discovered during an unrelated hospital visit.
Gabapentin Oral Solution Incident:
Pharmacy received a prescription stating ‘Take 5ml (50mg) at night’, correct direction should have been ‘Take 1ml (50mg) at night’.
Pharmacist did not catch the prescribing error; patient continued with incorrect dosing without adverse effects.
💊 Best Practices for Pharmacies Handling CD Oral Solutions:
Clearly state the dose and volume per administration on dispensing labels.
During dispensing, verify the patient understands the correct dosage.
Provide appropriate measuring devices, like oral syringes.
Directly contact prescribers for queries on high-risk drugs or complex conditions.
Document all communications in the patient’s Pharmacy Medical Record (PMR).
🩺 Prescriber Guidelines:
Write dosages in micrograms for amounts less than 1 mg to avoid confusion.
Communicate directly with pharmacies for complex issues; record all notes clearly in patient files.
Include patient's weight and date of weighing on paediatric prescriptions.
Be vigilant with Specialised Red Drugs—prescribe only within secondary care settings.
References:
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