Mar 12, 2014 4 min read

Lisa Bruce suspected something was wrong with her then 13-month-old daughter, Ava, one morning last fall when the normally happy, playful little girl – who had gone to an urgent care facility in Canonsburg the day before for treatment of an ear infection after her pediatrician’s office was closed for the day – seemed slow and lethargic.

“She was just staring into space, like she was catatonic. It was so upsetting,” said Bruce, a former teacher and stay-at-home mom.

Bruce, of North Strabane Township, immediately contacted her pediatrician at Children’s Community Pediatrics in McMurray, and was told to immediately stop giving Ava the amoxycillin the doctor had prescribed.

The amount of the antibiotic prescribed was dangerously high, and another dose could have sent Ava into cardiac arrest.

Ava, now 17 months old, is fine, but, according to Renee Brehio of the Institute for Safe Medication Practices near Philadelphia, that’s not always the case.

Medication errors are one of the most common medical errors – and one of the nation’s leading casues of death and injury – and each year, about 71,000 children are treated for accidental medication overdoses.

Bruce said the president of the urgent care facility apologized for the error, and the state Board of Medicine is investigating the incident but declined to comment on the case.

“The only thing I want out of this is to spread awareness,” said Bruce. “I just want to make parents aware of what can happen when they go in for something that might seem routine.”

The ISMP and the Agency for Healthcare Research and Quality, a federal agency, offered the following tips to help parents and their children avoid medication errors.

• Make sure that your child’s doctors know what prescriptions, over-the-counter medicines and dietary supplements, including vitamins and herbs, that your child is taking.

• Make sure your doctor knows your child’s weight. Especially in the case of children, medications are prescribed according to weight, and not having the accurate weight can result in an error. In Ava’s case, she was not weighed at the urgent care facility, although Bruce asked if her daughter should be weighed.

• Make sure your child’s doctor knows about any allergies and how your child reacts to medicines.

• When your child’s doctor writes you a prescription, make sure you can read it. If you can’t read the handwriting, it’s possible your pharmacist might not be able to either. Don’t be afraid to ask the doctor to print the name of the drug.

• When you pick up your child’s medicine from the pharmacy, ask if it is the medicine that the doctor prescribed.

One study by the Massachusetts College of Pharmacy and Allied Health Sciences found that 88 percent of medicine errors involved the wrong drug or the wrong dose, according to the AHRQ, so don’t hesitate to ask the pharmacist.

• Make sure you undertand what drugs your child is taking: the name of the medicine, what it’s for, if the dose is appropriate for your child based on his or her weight, how often the child is supposed to take it and for how long, possible side effects, and if the medicine is safe for your child to take with other medications or dietary supplements.

• Ask your pharmacist for the best device to measure your child’s liquid medicine. Also, ask questions if you’re not sure how to use the device. Brehio said that sometimes, people don’t understand the proper way to measure liquid medicines.

For example, many people use household teaspoons, which often don’t hold a teaspoon of liquid. Special devices, like marked oral syringes, help to measure the right dose.