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

Last updated
Citation
The Pharmaceutical Journal, PJ, 28 February 2015, Vol 294, No 7851;294(7851):DOI:10.1211/PJ.2015.20067871