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ISMP Medication Safety Alert

The importance of counseling when you fill a prescription: a cautionary tale

Whenever you get a prescription filled or refilled, be sure that the pharmacist talks with you about your medications. This means more than just telling you the name of the medication-if the medication needs to be measured, ask the pharmacist to show you how to measure it. A mother gave her 7-week-old baby 5 mL of Tagamet® (cimetidine) instead of 0.5 mL for acid reflux because a pharmacy technician gave her the wrong syringe. The technician told the mother that the "5" on the syringe meant 0.5 mL. After four doses, the baby was very drowsy, vomited and had loose stools. The mother took the baby to the emergency room for observation, but, fortunately, the baby did not have to be treated. When prescriptions are dispensed, no one but a pharmacist should be giving you advice about the medication. If a pharmacist does not offer to counsel you, insist on it.

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