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Reporting a Medication Error

Dangerous “toys”

4feb08b32fc2bca59f9db42b69cd4022 MOn October 14, 2011, The New York Times published a story about a 13- month-old boy who died after swallowing pills from a prescription medicine bottle. His parents had given him the bottle to play with as a rattle, believing he could not open the child-resistant cap.


 

The bottle contained Suboxone (buprenorphine and naloxone), a medicine used to treat people who are addicted to illegal or prescription pain medicines. The boy was put in his crib to sleep. His mother checked on him a short time later and found the bottle open. The pills had fallen out and one of them was wet. She took them away from him, gave him a bottle of milk, and went to sleep. In the morning, the boy was found unconscious in his crib. The parents called 911, but the child had died by the time he reached the hospital.

 

Using a syringe as a toy led to another recent accident, but in this case, the child fortunately survived. A nurse gave a young hospitalized girl an empty syringe to play with during the day. The girl used the syringe to drink liquids and eat ice cream. The next morning the girl called for the nurse saying she had pain in her chest and a cough. The girl told the nurse she had connected the syringe to her intravenous line and pushed the plunger in, pretending to give herself medicine. The syringe only contained air, but an injection of air into the bloodstream can be deadly. The child’s pain and shortness of breath were caused by the injected air, which had blocked the blood vessels leading to her lungs. Fortunately, steps were taken to treat the girl who recovered from this accident.

 

Stories like these should serve as a reminder that children should not be allowed to play with medicines (not even empty bottles) or other supplies used to administer medicines. Children are curious and creative. They like to explore and mimic the actions of adults. So, if they see you taking medicine or using a syringe, they will likely try to follow suit. Infants learn by putting things in their mouths, and even very young children have been able to open a child-resistant cap. To prevent accidents like these, keep medicines up and away and out of the reach of children (www.upandaway.org). Only allow children to hold and touch medical equipment when a healthcare professional feels it is necessary to ease a child’s anxiety—and then only under the direct supervision of the healthcare professional.

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