An incorrect label on croup medication led to a four-week-old baby turning “blue and floppy”, requiring CPR and being rushed to hospital by her mother.
The baby girl also stopped breathing after receiving the steroid dosage five times higher than what was prescribed.
In a report released today by the Health and Disability Commissioner, a pharmacist was found to have breached the code for failing to provide services of an appropriate standard.
The female baby was prescribed the oral steroid drug Redipred by her GP to treat symptoms of croup in May 2023. On the prescription form filled out by the GP, the dose of medication was specified to be 4.5mg daily administered orally.
A day later, the mother took her baby with her to collect her prescription, receiving the medication in a box which stated, “Give 4.5mls with food ONCE daily in the morning for a TWO-day course as directed.”
The report said on that same day, the baby began to cough, and the mother administered the medication as per the label instruction.
Mother carried out CPR on baby
“[The mother] described how [the baby] aspirated what she estimated to be about the last 0.5ml of the full 4.5ml dose and stopped breathing. [the mother] said [the baby] then turned blue and floppy. [the mother] carried out CPR and [the baby] started breathing again after about 10 seconds.”
The baby was taken to the emergency department where she was provisionally diagnosed with “inappropriate steroids use and dose”, prescribed emergency medication and admitted for overnight observation and monitoring.
The mother informed the triage nurse she had followed the label instructions from the pharmacy, and hospital staff inferred she had misread the dose on the label of the medication, the report said.
“[The mother] questioned herself, believing she had made a mistake and had caused [the baby] to stop breathing from an overdose of the medication.”
The mother rang the pharmacy to obtain a copy of the prescription to check it and was told by the locum pharmacist on duty there had been a dispensing error.
She admitted “she had not checked the label on the Redipred box against the prescription from the GP” and was described by the mother as “very apologetic” and “mortified”.
The medication label had been typed by a trainee pharmacy technician and then checked by the locum pharmacist. It was incorrectly labelled to give a 4.5ml dose instead of the prescribed 4.5mg — around -0.9ml.
“In addition to not properly checking the dispensed medication against the prescription, or not identifying the error on the prescription dosage, the pharmacist also failed to provide advice to the mother on how to administer the medication,” the report said.
Baby developed a heart murmur
The baby was discharged from the hospital on the afternoon of May 13 and the parents were advised to check with their GP regarding a heart murmur developed due to the overdose.
The mother expressed concern that the locum pharmacist called her and her husband six times on multiple numbers following the initial conversation to offer her assistance — despite being politely asked not to contact them again.
She said she had “felt harassed and did not feel it was her responsibility to ‘provide reassurance and effectively, professional supervision to the pharmacist who had made a grave error’.”
The report also described the mother feeling “alarmed” and “deeply uncomfortable” during these conversations, remarking that they felt “unprofessional and inappropriate”.
The locum pharmacist said she did not recall being asked not to contact the family again.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell said by not properly checking the dispensed medication against the prescription or identifying the error on the prescription dosage, thus allowing an incorrect dosage of medication to be dispensed, the locum pharmacist failed to adhere to the professional standards set by the Pharmacy Council of New Zealand and the pharmacy’s standard operating procedure.
“Accordingly, I find that [the locum pharmacist] breached Right 4(2)19 of the Code of Health and Disability Services Consumers’ Rights (the Code).”
Caldwell also said she had “some concerns” about the communications between the locum pharmacist and the mother following the events.
‘Clearly this was a stressful time’
“Whilst it is understandable that [the locum pharmacist] wanted to check on [the baby]’s condition, clearly it was a stressful time for [the mother] and her family.
“I accept that [the locum pharmacist]’s actions came from a place of concern, but she should have respected [the mother]’s request not to contact her further and should have maintained appropriate professional boundaries.”
The trainee pharmacy technician was also reminded of the importance of “slowing down and being meticulous” when inputting information from prescriptions because of the risk of errors.
Caldwell recommended the locum pharmacist provide a formal apology the family, provide evidence of completing a workbook titled Avoiding Medication Errors in Children, and complete training on paediatric prescriptions.
The pharmacy was also recommended to undertake a random audit of overall processing, dispensing and checking medication, yearly refresher training for dispensing errors, a review of the induction programme and the development of education and training in relation to the incident.