Overdosering van pipamperon uit een knijpflacon

Background

Medication is not always delivered in a safe dosing format. Up to 33% of medication errors can be attributed to confusing packaging or labelling.

Case description

A 6-year-old boy with ADHD, for which he was being treated with methylphenidate and pipamperone drops, was brought to the A&E department with signs of severe encephalopathy. He had apparently been given pipamperone in streams rather than in drops in the previous months. The pipamperone level in his blood was raised to toxic levels. The pipamperone drops were delivered in a plastic squeeze bottle (LDPE bottle), which makes correct dosing almost impossible. The treating psychiatrist and the prescribing GP had not noticed this medication error. The incident was reported to the Netherlands Pharmacovigilance Centre Lareb, the Netherlands Medicines Evaluation Board and the Portal for Patient Safety. A warning was also added to the Netherlands paediatric medication prescription website about pipamperone in a squeeze bottle.

Conclusion

Drug packaging can be a cause of intoxication. The treatment provider should be aware of this in cases of drug intoxication.

Conflict of interest and financial support: none declared.