Unintended Consequences: A Case of Metoclopramide and Paracetamol Packaging Confusion in an Infant

Ambika Nand Jha and Varsha Ratan Gaikwad

Published on: 2024-12-12

Abstract

Background: Adverse drug reactions (ADRs) pose a major challenge to global health, contributing to significant rates of illness and death. With the complexity of modern healthcare systems vigilant pharmacovigilance systems are essential to detect and manage these risks, thereby safeguarding patients and ensuring the rational use of medications. ADRs may arise from factors such as drug interactions, genetic predispositions, organ dysfunction, or inappropriate medication use. On the other hand, medication errors, which differ from ADRs, are preventable mistakes made during drug prescribing, dispensing, or administration, and can lead to adverse drug events (ADEs). Both ADRs and medication errors underscore the importance of careful monitoring, ongoing professional education, and a patient-centered approach to enhance treatment outcomes and minimize harm. Tackling these challenges is critical to improving the safety and quality of healthcare delivery.

Clinical Scenario: A 9-month-old male infant, initially managed for an upper respiratory tract infection with paracetamol, Cefixime, and Ofloxacin ear drops, developed symptoms of dizziness, weakness, and atypical oral sensations following inadvertent administration of metoclopramide suppositories due to packaging similarity. After referral to a tertiary care facility, comprehensive neurological and laboratory assessments, including brain imaging, revealed no significant abnormalities. The patient received intravenous hydration and a dose of paracetamol, with marked clinical improvement observed over a 24-hour period. He was discharged in stable condition, without any lasting sequelae.

Conclusion: This case underscores the risks of medication errors in pediatric care, particularly when medications have similar packaging. It highlights the need for clearer labelling, thorough medication reviews, and heightened awareness among healthcare providers and caregivers. Prompt intervention and proper monitoring are crucial in managing ADEs, and improving safety protocols and education can help prevent such incidents in the future. This emphasizes the need for vigilance in medication management to ensure patient safety, especially in vulnerable populations like infants.