A 4-week-old baby experienced a severe health crisis after being given a dose of Redipred steroid five times higher than prescribed. The infant stopped breathing, turned blue, and went limp after the mother administered the medication using a syringe.
The mother was following the instructions to give 4.5ml of the oral steroid when the baby inhaled the last 0.5ml and ceased breathing. She immediately performed CPR, which restored the baby’s breathing, and then rushed the child to the emergency department.
In a decision released today, the Deputy Health and Disability Commissioner reported that the overdose was due to a pharmacist error. Dr. Vanessa Caldwell stated that the medication was labeled with the incorrect dosage, which led to a critical situation requiring resuscitation and hospitalization.
Upon examination, the baby was otherwise healthy except for a minor heart murmur and was discharged the following day. Parents were advised to follow up with their GP or pediatrician regarding the murmur.
The mother reported that after intensive follow-up care with a private pediatrician, the baby’s medium-term outlook is good, though there are still concerns about potential long-term effects. She criticized the pharmacist for not checking the prescription properly, describing the oversight as “reckless and unreasonable.”
Error Details
The investigation revealed that the medication box should have indicated a dose of 0.9ml, but instead, it was labeled as 4.5ml. When the mother arrived at the hospital, she informed the triage nurse that she had administered the full 4.5ml dose according to the label.
Initially, hospital staff believed the mother had made a mistake. However, it was later confirmed that the error originated at the pharmacy. The locum pharmacist, identified as Ms. B, admitted she failed to verify the label against the prescription. This mistake occurred when a trainee pharmacy technician misread “4.5mg” as “4.5ml” and entered it into the system incorrectly.
Ms. B, who has been a pharmacist for nearly a decade, acknowledged her failure to catch the dosage error during the final check. Dr. Caldwell criticized Ms. B for not following proper pharmacy procedures and for not assessing the clinical appropriateness of the dose.
Concerns About Communication
Following the incident, Ms. B contacted the baby’s parents multiple times, which Dr. Caldwell found concerning. The pharmacist’s attempts to check on the baby and offer assistance were seen as unprofessional and intrusive during a stressful time for the family.
The mother felt uncomfortable and alarmed by the pharmacist’s repeated contacts and offers of help, which included an offer to sit with the baby. The pharmacist’s lawyer contested these claims, stating that the offer was misinterpreted and was intended to provide additional information rather than physical assistance.
Recommendations
The pharmacist has been instructed to issue a formal written apology to the baby’s parents. She has completed training on avoiding medication errors and maintaining professional boundaries. She must outline any improvements made to her practice within three months of the report.
The trainee pharmacy technician is required to review the importance of accuracy in prescription processing and complete a workbook on self-checking.
The pharmacy is advised to conduct a random audit of medication dispensing practices, implement yearly refresher training, and enhance its induction program for temporary staff. Additionally, the case should be used to develop ongoing education on dispensing processes, error management, and customer service for all staff.
Hannah Bartlett is an Open Justice reporter at NZME, based in Tauranga. She has covered court and local government matters for the Nelson Mail and worked as a radio reporter for Newstalk ZB.
