[Overdosing of pipamperone from a squeeze bottle]

Area of Science:

• Pediatric Neurology
• Clinical Pharmacology
• Patient Safety

Background:

• Medication errors frequently stem from unsafe dosing formats and unclear labeling.
• Approximately 33% of medication errors are linked to packaging or labeling confusion.

Observation:

• A child with ADHD experienced severe encephalopathy due to incorrect pipamperone administration.
• Pipamperone drops were dispensed in a low-density polyethylene (LDPE) squeeze bottle, facilitating inaccurate dosing.
• The child's blood pipamperone levels reached toxic concentrations.

Findings:

• The packaging format of pipamperone drops in a squeeze bottle made accurate dosing extremely difficult.
• Neither the treating psychiatrist nor the general practitioner identified this medication error.
• The incident highlights a critical failure in recognizing packaging-related medication errors.

Implications:

• Drug packaging design can directly contribute to patient intoxication.
• Healthcare providers must consider packaging as a potential factor in unexplained drug toxicity cases.
• Enhanced vigilance regarding medication packaging is crucial for preventing adverse drug events.