Published April 14, 2025
Over the weekend, a dad brought his 14-month child to urgent care due to a rash on the child’s stomach, legs, and face. The doctor diagnosed the child with hives and told the dad it could be due to a virus, a reaction toa new food, or something new in the child’s environment. The child was not taking any medicine and had not tried any new foods. They were also not exposed to any topical triggers such as a new lotion or detergent. The doctor sent a prescription to the pharmacy for a steroid, prednisolone 15 mg/5 mL with instructions to give 3 mL (9 mg) each day for three days.
The dad picked up the medicine from the outpatient pharmacy. When he returned home and read the label, he realized the pharmacist did not give him with an oral syringe, so he had no way to prepare a 3 mL dose. He returned to the pharmacy to obtain a syringe. This time when he returned home, he prepared 3 mL and recognized there was only enough medicine to give 2 doses of medicine, not 3 as prescribed. The bottle only had about 6 mL total volume.
At this point, the child’s parents became concerned that they could not trust the pharmacy and decided not to give the child the medicine. They planned to follow up with the child’s pediatrician on Monday morning.
Here’s what you can do: Whenever you receive a new prescription for your child, ask the pharmacist to review it with you. Take the bottle out of the bag and read the label when you are at the pharmacy. Make sure you understand how much medicine you will need to give your child for each dose. Make sure you know how to prepare a dose, especially if it is liquid medicine. If the medicine does not come with a measuring device (e.g., oral syringe), ask for one. Make sure the syringe is the right size; it should have markings to measure the dose your child needs. Show the pharmacist how you plan to draw up the dose. If you do not think there is enough medicine in the bottle, based on how much the label says to give, ask the pharmacist. This can help identify if there was a potential error.
