Case study - Rishi 

Learning from pharmacy events

Six-year-old Rishi had been unwell since Monday with ear pain and a high temperature. His mum, Preeti, kept him out of school and had been giving him age-appropriate doses of liquid paracetamol, as recommended by the local Boots pharmacist.

By Thursday, Rishi was still feeling poorly and had spent much of the previous night awake, fretful and crying with pain. Preeti managed to get him an appointment with their GP, who diagnosed a severe bacterial middle ear infection and prescribed a course of flucloxacillin. A prescription was sent electronically to the nearby Boots pharmacy.

Once Rishi was settled back at home, with a neighbour looking after him, Preeti went to collect his dispensed medication. This was handed over to Preeti with advice to store the medicine in the fridge, to give Rishi one 5ml spoonful four times a day for seven days and to then discard any remaining medicine.

Once home, Preeti took two very different-looking bottles of medicine out of the bag and noted the dosage instructions on the dispensing label of each, which matched what she had been told. She gave Rishi a 5ml dose of the medicine from each bottle and continued to do so four times daily over the next few days.

By Sunday evening, Preeti realised that the medicine in each bottle was rapidly running out. On Monday morning, she telephoned the pharmacy to ask how she was expected to continue giving Rishi his medicine for a further two to three days when it was already almost all used up.

It was identified that Rishi had been provided with two bottles of flucloxacillin 250mg/5ml oral solution from different manufacturers, with the intention that the contents of one bottle were used before starting the second bottle. This had not been explained to Preeti, resulting in her giving Rishi twice the prescribed dose of flucloxacillin – which was also twice the maximum dose recommended for a child of Rishi's age – for four days.