Published March 4, 2025
There have been many cases where oral medicines were given out as a powder instead of being mixed with water into a liquid before leaving the pharmacy. Most of these cases involved antibiotics for children. Sometimes, water was not added to the powder, or not enough water was added. Although we have written about these types of error, we still get reports of these mistakes.
In one case, a pharmacy gave out amoxicillin powder. Luckily, the child's parent, who is a nurse, knew it needed to be mixed with water first. When the parent called the pharmacy, they were hung up on and had to call multiple times. The pharmacy was closing, so the parent couldn't talk to a pharmacist. Unfortunately, the child had to wait until the next day to start the medicine.
In another case, the parents of a 10-month-old were given amoxicillin with instructions to give 4.7 mL twice a day for 10 days. The parents followed the instructions but ran out of medicine after 6 days. Unfortunately, the pharmacy's machine that adds water to powder wasn't working right, so the medicine had too little water and was too strong. The child had some side effects from the higher dose, such as dark, loose stools; fussiness; nausea; and poor appetite.
In a recent case, a child was to receive amoxicillin for anear infection. However, the medicine was dispensed as a powder. When the parent called the pharmacy, the technician told them they could add water themselves. The parent did not feel comfortable doing that, so they took the medicine back to the pharmacy to have it mixed.
Pharmacies must take steps to prevent these mistakes. Since we keep hearing about these errors, it is important to review ways to prevent them.
Here’s what you can do: Here are some clues that indicate the pharmacist has forgotten to add the water to the powdered medicine:
When picking up a prescription, open the bag and read the label. If you expect a liquid medicine, shake the bottle to make sure it contains a liquid. Use the oral syringe that the pharmacist provides you with or ask the pharmacist for an appropriate device. Review with the pharmacist how to measure the medicine using the oral syringe. Practice measuring a dose in front of the pharmacist.
If someone else picked up the medicine for you or it was delivered, again make sure it is a liquid by shaking the bottle. If it is not what you expect, NEVER try to add water to a powdered medicine yourself. The pharmacy technician should NOT have said the parent could add water themselves. Bring it back to the pharmacy to have it mixed. The amount of water used must be carefully measured to be sure that each dose has the correct amount of medicine in it. If you notice the medicine will not last (e.g., needed for 10 days, but running low after a few days), it may not have been mixed correctly. Contact your pharmacist as soon as possible.
