Caution needed with different strengths of medicines

I would like to highlight a risk I have encountered with “specials” medicines. My newborn daughter was discharged from hospital with a bag of medicines, including furosemide liquid 5mg/5ml and spironolactone liquid 10mg/5ml. When my husband collected a follow up prescription from our local community pharmacy, it contained furosemide liquid 20mg/5ml and spironolactone liquid 5mg/5ml. Therefore, the amount to give per dose had to be adjusted accordingly. I am concerned that sleep-deprived, stressed parents with no healthcare background would have continued to administer the old dose because, at no point, was my husband or I counselled that the strengths of the medicine have changed and that the amount we should give should change as well.

I urge all hospital and community pharmacists to counsel patients regarding specials and make sure they have a good understanding of the concentration and dose of the medicine. Patients also need to be made aware that the concentration and, therefore, the dose may potentially change. Perhaps there is a need to consolidate the number of different concentrations of specials. Is there really a need for five different strengths of spironolactone? This will just increase the risk of administration errors.

Dawn Fleming

Ilkley, West Yorkshire