A Cleveland-area child died after receiving an improperly-mixed medication as part of her chemotherapy regimen. The actual dose was mixed by a pharmacy technician. The error was uncovered as part of an investigation which followed the child’s death.
The work of the pharmacy technician was being supervised by a licensed pharmacist. However, he failed to discover the medication error before releasing the medication to be used on the child.
This incident demonstrates the special vulnerability children have to medication errors. Proper medication dosing often depends on the age and weight of the patient. Many potent medications are not made in standard doses for children, requiring that they be specialy prepared by the pharmacy. Any error in preparation is likely to result in a massive overdose. This can have fatal results.