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Reporting a Medication Error

Wrong Patient Error Results in ED Visit for a Child

Published November 18, 2024

A doctor ordered an antibiotic for a 13-year-old child to treat an infection. The child’s mother went to their pharmacy to pick up the prescription. However, the pharmacy gave her a prescription for a different person with a similar last name. The medicine she received was Suboxone (buprenorphine and naloxone) 8 mg/2 mg sublingual film, which is used to treat opioid use disorder. The pharmacy did not review the prescription label with the mother. When she arrived home, believing she had received the prescribed antibiotic, she gave a dose of the Suboxone to her child. Shortly after taking the medicine, the child became extremely tired and started vomiting. The mother looked at the prescription label and realized the medicine was for a different person. She called Poison Control (1-800-222-1222) who told her to take the child to the emergency department (ED).

Wrong patient errors are one of the more common event types reported by consumers and community pharmacists. ISMP has written about wrong patient errors many times over the years. These errors have resulted in potential and actual serious adverse events.

Here’s what you can do: When picking up medicines at the pharmacy, state your name or the name of the person whose medicine you are picking up. The staff person should ask for an additional identifier such as the person’s address or date of birth. Open the bag before leaving the counter and look at the medicine package and label. Make sure the name is spelled correctly on the prescription label. If you or a loved one has a common name or a name spelled differently, be extra cautious. Ensure the medicine is what you expect by verifying the drug name, dose, and directions. Ask to speak to the pharmacist to review how to take or give the medicine. This can also help catch errors if the medicine, dose, or directions are different than you expect, or if the reason for taking the medicine does not match what it is supposed to treat. If the medicine is not what you expected, don’t be afraid to tell the pharmacist you do not think it is right.

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