Clozapine Toxicity in Two Young Siblings Due to a Pharmacy Dispensing Error: a Pediatric Case Report.

Hannah St FrancisMadeline H RennyRana BiaryMary Ann HowlandMark K Su

Published in: Journal of medical toxicology : official journal of the American College of Medical Toxicology (2022)

We report two cases of pediatric clozapine toxicity due to a pharmacy dispensing error. The error was due, in part, to similarly named medications being stored adjacent to each other on a shelf. Dispensing errors are not rare occurrences and their root causes are multi-factorial. This case demonstrates the importance of reducing such errors, particularly for medications with potential for severe toxicity.

Keyphrases

case report
oxidative stress
patient safety
adverse drug
oxide nanoparticles
emergency department
room temperature
autism spectrum disorder
risk assessment
middle aged
drug induced
ionic liquid