We report a rare medication error, and its management of a preterm female baby who accidently received formula milk intravenously over two hours through central catheter. She developed leukocytosis, thrombocytopenia, transient metabolic acidosis, superficial thrombophlebitis and thrombosis of greater saphenous vein. She received supportive care with observation of her vital signs, including art...

Contributors and acknowledgements: Xuan Hao Chan, International Pharmaceutical Federation; Jane Sutton, University of Bath, United Kingdom; International Pharmaceutical Federation (FIP); FIP Patient Safety Working Group; World Health Organization World Alliance for Patient Safety; Finnish Cultural Foundation; Finnish Pharmacists’ Association; Faculty of Pharmacy, University of Helsinki; Pharmac...

INTRODUCTION The World Health Organisation recognizes confusing drug names as one of the most common causes of medication errors. Other factors include spelling, phonetic, or packaging similarities. CASE PRESENTATION We presented a case report of an inadvertent administration of a non-ocular pharmaceutical product (Novasone lotion) into the eye of an octogenarian individual, and briefly revie...

We present a teenage boy with recent onset of seizures, who was erroneously treated with a large dose of an antiseizure medication as a result of drug mix-up. The ensuing drug toxicity caused vertical gaze palsy, an unusual manifestation related to overdose of the agent. Timely recognition of the error and discontinuation of the drug resulted in complete recovery to baseline.