Concerning Case Of Infant’s Mother Finding Incorrect Directions On Paediatric Propranolol Oral Liquid Label

[Liz Seyi]

In a story that further highlights the critical importance of developing and assessing the competencies required for safe medication practice associated with bodyweight and body surface area dosage problems - Pharmacy Times recently reported a prescriber error for a three-month-old patient.
What was the background of this case?
Writing for the news outlet, Michael J. Gaunt, PharmD – a senior director of error reporting programs at the Horsham, Pennsylvania-based Institute for Safe Medication Practices – stated that an oral liquid medication (Propranolol) had been prescribed for a 7.2kg infant with a fast-growing benign vascular tumour, infantile hemangioma.
According to the Pharmacy Times article, the pharmacy reached out to the physician’s office to seek clarity about the medication order.
On arrival to pick up the prescription, the parent was dispensed 20 mg/5 mL (4 mg/mL) of Propranolol. The following instructions accompanied the medication order: “Administer 3.5 mL once on day 1, administer 3.5 mL twice daily for the next 6 days, then administer 7.5 mL twice daily for a maintenance dose.”
Gaunt observed that based on the dispensed concentration, this would calculate as 14 mg once on the first day (1.9 mg/kg/day), 14 mg twice a day for the following six days (3.9 mg/kg/day), and then for the maintenance dose, two doses of 30 mg a day (8.3 mg/kg/day).
The above calculation shows a much higher maintenance dose than the usual daily oral maintenance dose of 1 to 3 mg/kg/day for child and neonate patients for this indication.
Mother’s persistently expressed concerns helped identify the error
The Pharmacy Times report further stated that when the mother visited the pharmacy, she was “neither counselled nor provided with an oral syringe to administer her medication to the infant.”
Gaunt added that on the mother’s return home, she called the pharmacist expressing concern about the dose. Although the pharmacist did confirm the dose was higher than recommended for a 7.2kg neonate with infantile hemangioma, they also stated that “it should be fine if this is how the doctor wanted it.”
The pharmacist suggested that if the parent was still concerned about the prescribed dose, she could directly call the physician’s office. The mother went on to precisely do that.
It emerged that the prescribed dose the pharmacy had stated on the pharmacy label was incorrect. The prescriber explained to the mother that, when the pharmacist called seeking clarification, they were mistakenly given dosing directions in mL, rather than mg.
The intended instructions were actually “3.5 mg (0.88 mL) for the first day (0.49 mg/kg/day), 3.5 mg (0.88 mL) twice daily for the following 6 days (0.97 mg/kg/day), followed by 7.5 mg (1.88 mL) twice daily (2.1 mg/kg/day) for the maintenance dose.”
Ultimately, we can only be extremely thankful that the patients mother insisted on challenging the prescription, which allowed for the error to be identified before the medication was given to the neonate patient.
And of course, it is another firm reminder of how crucial it is to follow safe practice recommendations in relation to administering and prescribing drug dosages.
The safeMedicate Bodyweight and Body Surface Area Calculations Module
The safeMedicateBodyweight and Body Surface Area Calculations Module helps eliminate these unfortunate errors by requiring you to factor either the patient’s bodyweight or body surface area (BSA) into the problem-solving process and to use that information in conjunction with the dose formula found in the monograph to verify the accuracy of the prescribed dose. In any given safeMedicate assessment within this module, a proportion of dosage problems will contain a prescriber error that must be identified by the user and the problem solving process halted, just as you would do in practice.
Would you like to learn more about how safeMedicate can develop and assess your skills with the world’s leading resource for healthcare students and practitioners? With over 43,000 Authentic Dosage Problems to assess your competence, visit our website for more information or you can contact our dedicated team here with any questions.

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