Published January 21, 2025
During an urgent care visit, a 3-year-old child received an intramuscular injection of dexamethasone intended for another patient. Dexamethasone isa steroid that relieves inflammation and swelling in various parts of the body. It is used to treat a wide variety of conditions, including allergic reactions, skin conditions, asthma, cancer, and nausea and vomiting.
Before the child was seen by the doctor, a nurse entered the exam room with the injection. She told the child and mother that she had an injection to administer, but she did not verify the child’s name or date of birth. Nor did the nurse mention the name of the medicine or why it was needed. The mother questioned the nurse about the injection and learned it was dexamethasone. She then told the nurse that her child had not been seen by the doctor yet. Unfortunately, this fact did not cause the nurse to double-check the medicine. Instead, she insisted that the medicine had been prescribed for the child. The mother agreed and allowed the nurse to administer the injection to her child.
When the doctor came into the exam room for the first time to evaluate the child, the mother asked about the injection. The doctor informed the mother that the dexamethasone injection was intended for another patient in a different exam room, not for her child.
After the visit, the child’s mother went to the pharmacy to pick up a prescription for an antibiotic for her daughter. At the pharmacy, there was also a prescription for prednisolone for her daughter. Prednisolone is an oral steroid. The mother called the urgent care asking if the prednisolone prescription was a mistake because the doctor had not mentioned this medicine during the visit, and it was not listed on the child’s discharge paperwork. The doctor told her that it was not a mistake. An oral steroid had been prescribed for her daughter in a gradually declining dose because she had received an injectable steroid in the office. This was necessary because if steroids are stopped abruptly, they can cause damage to the kidneys.
Here’s what you can do: If you suspect an error, speak up, as this mother did, but stand your ground and insist that the healthcare provider verifies everything and involves you in the process. Do not be easily convinced that the healthcare provider is right, and you are wrong, if you suspect an error and the explanation doesn’t make sense to you. Don’t be afraid to ask to speak to another healthcare provider. Speak up until you are satisfied.
