Should potential incorrect dosage instructions be reported?
Posted by moomeymoo@reddit | AskUK | View on Reddit | 60 comments
A doctor prescribed my 4 month old a medication. The instructions were to give it to her after every feed but the leaflet and NHS website said 4 times a day.
I asked the pharmacist which it was, my daughter can feed 12 times a day some days so that would be 3x more than the leaflet says. The pharmacist said that she legally had to say what the doctor had written but the normal dose is only 4x a day. I had to call the doctors to confirm and they said it was only 4 times.
I could have given my infant too much medicine had I not read the leaflet. It seems like a too higher dosage of this particular one doesn’t cause any major issues but it says that if children take too much you should contact a doctor or emergency department. Also, it’s not really the point - the instruction should be correct.
Firstly, I thought the job of pharmacists was to check this stuff and challenge it if it seems wrong.
Secondly, should I be following up with the doctors about, what I believe could have been a serious mistake?
Leather_Manager98@reddit
Btw the pharmacist is incorrect. If they believed the instructions to be wrong, they have the duty of care to query this with the doctor before dispensing
raspberryamphetamine@reddit
Really? I had a pharmacist insist the prescription was wrong but she wouldn’t contact the prescribing doctor, she said she would issue the medication but she was going to alter the prescribed dosage and preparation instructions to the “correct” amount before she would hand it over. She was entirely wrong as well and her instructions would have only given my daughter 20% of what she needed!
Warden_Sco@reddit
They shouldn't dispense it and you have to go back to the doctor to have it corrected.
raspberryamphetamine@reddit
It was preloaded clot busting medications for post surgery venous clots that I had to make stock solutions with and then draw up the correct amount based on the dosage my daughter needed so the prescription item itself wouldn’t change and wasn’t the issue, but she was entirely wrong on how you calculate how much to inject when it’s from a stock solution. She wouldn’t ring the doctor because she said she didn’t have an issue with what medication it was or the amount she needed but that the instructions I had on the paperwork which told me how to make and draw that amount were wrong so she wanted to rewrite them first. What we had been doing at the hospital already was right, but she wasn’t accounting for the fact that the medication was bulked out with saline, so she was trying to have it labelled on reissued instructions that I had to draw 0.096ml instead of 0.46ml to go in her cath.
Leather_Manager98@reddit
They can't correct it without doctors approval... This is something that is reportable to gphc. They do have the right to refuse to dispense the medication if they believe it's clinically inappropriate eg the dosage is wrong. But they can't 're-prescribe' it unless it's a medication that can be issued by a pharmacist (there's some meds like that, not many though)
raspberryamphetamine@reddit
I had to drive all the way back to Alder Hey to have it dispensed in the end! She was happy to give me the medication because it was pre loaded clot busting syringes that I was using to make stock solutions with saline and then draw up the correct amount to put through her subcutaneous cath, but she was adamant that if I wanted it right then from her that she would only give it with her rewritten draw and instructions on the printed labels. I wasn’t about to start messing with that! It was weird because she was happy to hand over the ingredients but only if she got to change “0.46ml of stock solution” to “0.096ml”.
Kiss_It_Goodbyeee@reddit
Exactly this! The pharmcist is responsible for checking any and all prescriptions. They can and do correct doctors.
If anyone needs to be reported it's the pharmacist, if they really said that and if it was indeed a pharmacist.
Afinkawan@reddit
Legally the pharmacist is more responsible than the doctor.
moomeymoo@reddit (OP)
They really did say that. They work for the local pharmacy and were who I was given to speak to when questioning the dose. I have to assume they have the relevant qualifications.
moomeymoo@reddit (OP)
This was what I thought! She just kept repeating that she was legally obliged to write what the doctor had written.
raspberryamphetamine@reddit
My pharmacist went the other way, she wouldn’t prescribe the medication until she’d altered the dosage and instructions herself because she (falsely) believed they had been miscalculated for dosage.
Hot_Day_9782@reddit
The pharmacist is correct that they legally can only dispense what’s written on the prescription. They can’t alter the directions BUT they definitely should have queried it with the doctor before dispensing, and then asked for a new prescription with the correct dose.
anti-sugar_dependant@reddit
I had a prescription queried last week because the Dr prescribed me 4 doses, which is enough for 1 year, and the pharmacist had never seen that before so they checked with my GP. Took more than a week because of the bank holiday but I guess my GP replied today because I got a notification to say it'd been processed. So you're right, the pharmacist should have queried it, and they're wrong for saying they have to say what the Dr says.
Ok-Rain6295@reddit
Was she the pharmacist or a pharmacy technician? Often the person serving you isn’t actually the pharmacist- they’re usually in the back dispensing.
Vanilla_EveryTime@reddit
This. Seems too bad to be true. Pharmacists know better than any doctor when it comes to medication and even the doctor would be glad to have a pharmacist point this out.
Astropoppet@reddit
Which can't be true, seeing as she is legally obliged to ensure that the instruction is correct
DoingItWellBitch@reddit
Yeah, exactly. I've had a pharmacist catch a doctor's mistake. They called up the Drs and tried to sort it for me.
geekroick@reddit
You can make a formal complaint to your local surgery/practice, I wouldn't count on getting much by way of a response other than a generic 'your comments have been taken on board', though.
roko5717@reddit
I mean what else should they say? If an error was indeed made then, but no harm occurred, then all the practice can do is take the feedback and try make sure it doesn’t happen again.
Randystarbuxx@reddit
This is a classic case of no harm no foul..
TorakMcLaren@reddit
Absolutely not. It's a near miss, which should absolutely be reported. The purpose of that isn't to get somebody into trouble, but to make sure that no harm comes from a similar situation in the future.
Randystarbuxx@reddit
Why is responsibility always devolved. I wouldn’t be giving my child any medicines without reading the leaflet.
TorakMcLaren@reddit
It's not. You can, you should, have a system with multiple points of failure. A failure at any point should be reported, considered, and corrected. That's how you do safety.
But in any case, it sounds like you're somebody with the wherewithal to think that way. Not everybody is capable of that, or capable of properly understanding dosage etc, and therefore are reliant on registered medical professionals to do their job properly.
Randystarbuxx@reddit
I’d be interested to see a picture of what it says on the label the pharmacist printed.
TorakMcLaren@reddit
Again, multiple points of failure
Randystarbuxx@reddit
That would be one of the barriers and seems to be the crux of the complaint….
TorakMcLaren@reddit
I wouldn't say that the specific label printed by the pharmacist is the crux. The main issue is that there's a conflict between the info given by the Dr and the info in the booklet, which suggests the Dr may not have fully understood the dosage. Or, they may not have realised that kids of that age feed more than 4x a day, which might mean them over-prescribing more than just that to other people.
LongjumpingLab3092@reddit
Wtf? It could have done serious damage to a baby?
Randystarbuxx@reddit
But it didn’t. I assume the administrator of the medicine bares the responsibility for dosing…..
melancholyy-scorpio@reddit
What an insane take.
TrainingCranberry199@reddit
I am a doctor, this is neither legal nor medical advice. Instructions are mostly automated and so when you prescribe a medication you just click the right thing. They are humans and sometimes click the wrong one. Pharmacists often contact doctors and the doctors are grateful for the correction. It’s hard to comprehend what it’s like making 200 actions per day that may harm someone. I don’t know about this case but a complaint or message of feedback would be gratefully received by your practise - in the even there’s a good reason for the discrepancy this will be communicated to you. Just act in good faith.
AliceMorgon@reddit
Agreed, I did data entry for a medical practice digitising all their patient records from 14 to 18 and there are SO MANY FIELDS and after hours and hours of staring at a screen it’s just so easy to miss a field or click the wrong option. An “initiative”🙄 designed to reduce errors has actually probably made the working environment more ripe for them.
Historical-Concept-8@reddit
I think the doctor was under the assumption that it’s the typical 3 meals a day? I don’t know how old your infant is.
If your little one is tiny then milk every 2-3 hours. Depends on the context? If older, I would’ve presumed after the main meals. Breakfast, lunch, and dinner.
Glad you clarified and also read the leaflet. Not blaming you, but just double check how long between doses with your doctor as a standard to double check.
Hope your little one feels better soon!
Great_Cucumber2924@reddit
A lot of older babies and toddlers breastfeed every few hours, day and night.
Mental_Body_5496@reddit
Some people dont seem to understand how serious this could be- a friends baby was injected with the wrong dose of a medication for another baby and she is brain damaged from it ! They are still fighting the trust for suitable compensation after 3 years and my friend had to give up her job as a police officer !
Great_Cucumber2924@reddit
OP says the leaflet states too much could cause an upset stomach so in this case fortunately it wasn’t such a grave error but I agree it should be reported to the practice and the pharmacy for their learning.
Poo_Poo_La_Foo@reddit
Also babies can feed wildly different times from child to child. So that would be absurd dosing!
e_lemonsqueezer@reddit
Sometimes leaflets are fairly rigid in their dosing regime and the real life scenario is different. Have you checked the BNF for children (the British national formulary)? As this may have more flexibility than the leaflet. If you just google ‘bnfc +[drug name] it should come up.
All leaflets will say contact a doctor if too much is given/taken, this is just standard legal protection for all drug companies.
If it’s way out compared to the BNFC then yes I would flag back to the GP and clarify what dosing they actually want.
Mental_Body_5496@reddit
Why would an ordinary mum even know what the BNF is (dont get me started on CCG/ICB variations)???
e_lemonsqueezer@reddit
No of course not, I was just suggesting an alternative option for OP to check rather than assuming that the product literature is correct and the GP was incorrect.
Profession-Unable@reddit
OP has already spoken to the doctor and confirmed the dosage was incorrect.
e_lemonsqueezer@reddit
Where does it say this in the OP? They’re literally asking whether they should report it?
Profession-Unable@reddit
Second paragraph, last sentence.
e_lemonsqueezer@reddit
Oh yeah totally missed that. So if they’ve already spoken to the gp, what else is there to do?
Profession-Unable@reddit
I think she’s asking if she should be making a formal complaint.
e_lemonsqueezer@reddit
I’m so intrigued why everyone assumes OP is female.
Fair enough, they can complain to the practice manager I guess, but I’m not sure what they actually want from the complaint. Awareness that it’s happened? Presumably the person who prescribed it is already aware. It’s not like incorrect dosing that was caught and no harm done is going to result in a GMC referral.
Profession-Unable@reddit
I don’t know about anyone else but I recognised her username from another subreddit.
I think it’s perfectly reasonable to want to reach out and try to ensure that it doesn’t happen again. Yes, the doctor clarified the error but I don’t see a problem with making sure the practice manager is aware. No harm was caused this time but, with a different medication, there could have been a worse outcome. Mistakes don’t get fixed if people aren’t aware of them.
Mental_Body_5496@reddit
Our local one is really hard to navigate and understand - i have a medically complex child !
Apologies it didn't come over to me as how I realise now you intended it to.
ComfyGreenGorilla@reddit
Seems like you’ve confused normal gaviscon and gaviscon infant and got the complete wrong end of the stick. Unless something seriously has gone wrong. You still need clarification, speak to a health care professional.
moomeymoo@reddit (OP)
She hasn’t been prescribed Gaviscon. I’m not sure where you got that from.
As I say in the post, I called the doctor and got the clarification that it should be 4x a day, not after every feed.
ComfyGreenGorilla@reddit
Fair enough what was the medication then and the directions on the label?
bumbleb33-@reddit
If it's something like Gaviscon I've had it prescribed for each feed before because we were trying to get the reflux under control and my GP wanted to follow up very soon to see if it had made a difference. Are you expecting some follow up to see if the particular medication is working well? Could it be an off licence dose?
I'd be asking for clarification before making a complaint.
Taken_Abroad_Book@reddit
Check with the doctor.
The leaflet for my 6 year old daughters 5mg Nitrazapam tablets say they're for 12 year olds and older.
She takes 7.5mg twice per day and has done as years as prescribed for a really rare epilepsy 🤷
She's also had other meds in rotation that the leaflet either says it's not for her agegroup or she's on a much bigger dose than the leaflet.
Going off label is funky.
Zivasper321@reddit
It would be interesting to know what the medication is to assess severity. Doctors can absolutely prescribe more than what the leaflet says in some cases. There isn't always a blanket same dose for everyone, it can depend on indication, weight etc. for some medications, not all. It could be the doctor was correct but then backtracked to give peace of mind if there isn't much difference in it. Or they could have over prescribed. But, as a pharmacist myself, it is the pharmacists job to pick that up.
bakedtattie246@reddit
So sometimes, like a consultant at a hospital for for example, medical professionals can prescribe doses that are ‘not licensed’ (not very common/rare/over the recommendation) if there is a clear clinical need. However, the doctor fucked up, and that is part of a pharmacists job (to catch doctor fuck ups) as they study medication, doctors don’t and are human therefore will fuck up. I truly do think the pharmacist should have thought like ‘this is out of the norm, maybe I should check this?’ but whatever. I think you’re well within your right to let the practice know, and maybe let the pharmacy know for a better experience next time.
Ok-Personality-6630@reddit
I had the same thing happen. The pharmacy raised a complaint with themselves on my behalf. It would help to identify if someone is making the same mistakes.
Specialist-Web7854@reddit
It depends, what is the medication?
VolcanicBear@reddit
Did you read the full info sheet?
Pretty much every medication I have ever taken has said "but not more than X times per day".
moomeymoo@reddit (OP)
Yes. It says 4x a day for babies, children, and adults. And 1x a day for newborns.
It says taking too much is unlikely to cause harm other than an upset stomach but if children take too much you should seek medical advice.
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