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Massive clonidine overdose in a paediatric patient due to a pharmacy compounding error and a primer on investigating

Brian Patrick Murray1, Matthew David Sheridan2, Hannah Hays3

  • 1Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, Ohio, USA bpatmurray@gmail.com.

BMJ Case Reports
|August 25, 2025
PubMed

Insights

A pediatric patient experienced a severe clonidine overdose due to a pharmacy compounding error, leading to altered mental status and paralytic ileus. This case underscores the importance of investigating pharmacy errors in pediatric overdose cases.

Area of Science:

  • Pediatric Emergency Medicine
  • Clinical Pharmacy
  • Toxicology

Background:

  • Clonidine overdose can cause significant toxicity in children.
  • Pharmacy compounding errors can lead to accidental medication overdoses.

Purpose of the Study:

  • To report a case of severe pediatric clonidine overdose from a pharmacy compounding error.
  • To highlight clinical indicators and investigative steps for suspected compounding errors.

Main Methods:

  • Case report of a 2-5-year-old male presenting with overdose symptoms.
  • Review of pharmacy compounding procedures and State Board of Pharmacy investigation findings.

Main Results:

  • Accidental 1000-fold clonidine overdose occurred due to using powder instead of tablets.
  • Patient developed altered mental status, bradycardia, hypertension, and paralytic ileus requiring ICU admission and nasogastric tube placement.

Conclusions:

  • Pharmacy compounding errors are a critical consideration in pediatric overdose cases.
  • Clinicians should elicit detailed medication history to identify potential compounding errors.
  • Prompt investigation and management are crucial for adverse events stemming from medication errors.

Keywords:
Contraindications and precautionsHealthcare improvement and patient safetyPaediatrics (drugs and medicines)Poisoning

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