Loving Intentions: A Medication Error

Saleem (not his real name) was a Syrian-born toddler, brought to the hospital with a viral infection, feverish, and bleeding from the nose on October 29. His mother, an X-ray technologist at the hospital, had given medicine to her two-year old son when he first became ill. Then, when Saleem started bleeding, she took him to the hospital.

The boy died soon afterward. Based on a liver biopsy, the physician in charge of the investigation into Saleem’s death found necrosis (tissue that had died from a lack of oxygen) and fatty tissue in his liver. He, the pathologist, and the government’s health department investigators are 98% sure the cause was a drug interaction or drug sensitivity.

Type of error:
This was a preventable adverse drug reaction, from the wrong drug, or perhaps from an overdose of the right drug.

Causes:
Apparently, Saleem’s mother had inadvertently caused her son’s death by giving him the wrong medication or dosage.

Ways to prevent similar tragedies:
Parents and grandparents should avoid giving one child’s prescribed medication to another young child; an infant’s organs may not be able to metabolize (break down and use) the medicine.

Readers: Is it ever acceptable for a parent or grandparent to give one child’s prescribed medication to a different child? When? Do you know of similar errors?

Read more in Nina Muslim's article, “Toddler’s death due to adverse drug reaction” GulfNews.com, Nov. 6, 2006.