Surreal illustration of medication error concept.

Medication Errors: A Shocking Case and How to Prevent Them

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Rhea Morgan in Health & Wellness December 2025 • 5 min read.

"Learn how a concentration mix-up in sodium supplementation nearly cost a child his life, and discover key strategies for safer medication practices."


Medication errors represent a significant threat to patient safety, with potentially devastating consequences. While healthcare systems implement various safeguards, mistakes still occur, underscoring the need for continuous improvement and vigilance at all levels. A recent case highlights how a seemingly minor error in medication concentration nearly resulted in tragedy for an 11-year-old boy, emphasizing the multi-factorial nature of drug errors.

This article delves into a case study published in the Archives of Disease in Childhood, detailing a severe incident of hypernatremia (dangerously high sodium levels) caused by a mix-up in sodium supplementation. We will explore the sequence of events, the factors that contributed to the error, and the critical lessons learned. By understanding the vulnerabilities exposed in this case, healthcare professionals and caregivers can implement strategies to minimize the risk of similar incidents.

The goal is to equip you with actionable insights to improve medication safety practices, protect vulnerable patients, and promote a culture of continuous learning within healthcare settings. Special focus will be given to labeling and pharmacy dispensing levels. The case underscores that medication errors are almost always multifactorial.

The Case: A Near-Fatal Sodium Supplementation Error

Surreal illustration of medication error concept.

An 11-year-old boy with lissencephaly, severe global developmental delay, and a seizure disorder was admitted to the hospital in critical condition. He presented with a four-day history of diarrhea, reduced responsiveness, and abnormal breathing. His medical history included sodium supplementation via a percutaneous endoscopic gastrostomy (PEG) tube.

Upon arrival, the boy's condition was grave: his Glasgow Coma Scale (GCS) score was 3, indicating a significantly decreased level of consciousness. He required immediate intubation and ventilation to support his breathing. His cardiovascular system was compromised, necessitating fluid resuscitation and an adrenaline infusion. Presumed sepsis was also treated.

  • Initial Blood Tests: His initial blood tests revealed dangerously high sodium levels (hypernatremia) at >200mmol/l, elevated chloride levels (hyperchloraemia), thrombocytopenia (low platelet count), and coagulopathy (impaired blood clotting). A chest X-ray confirmed pneumonia.
  • The Mistake: Further investigation revealed that the boy had been receiving a sodium supplement five times more concentrated than prescribed for six days (5mmol/ml instead of 1mmol/ml). Both concentrations were available in identical packaging.
The patient received intensive care support, including careful correction of the hypernatremia over four days, primarily with 0.9% sodium chloride. Intravenous potassium chloride infusions addressed severe hypokalemia (low potassium levels) that had caused life-threatening arrhythmias. Other biochemical abnormalities gradually improved. Though thrombocytopenia persisted for four days, the disseminated intravascular coagulation (DIC) improved with vitamin K therapy. Adrenaline support was weaned over five days.

Key Takeaways and Prevention Strategies

This case underscores the critical importance of a multi-faceted approach to medication safety. No single intervention can completely eliminate the risk of errors, but a combination of strategies can significantly reduce the likelihood of harm. These strategies include:

<ul><li><b>Clear Product Labeling:</b> Standardized labeling practices are crucial to differentiate between medications and concentrations. Clear, prominent labeling that highlights the strength and dosage of a medication can help prevent mix-ups.</li><li><b>Pharmacist Vigilance:</b> Pharmacists play a vital role in verifying prescriptions and identifying potential errors before medications reach patients. Independent double checks and careful review of medication orders can catch mistakes that might otherwise slip through the cracks.</li><li><b>Standardized Concentrations:</b> Whenever possible, using standardized concentrations of medications can reduce the risk of errors. When different concentrations are necessary, clear differentiation in packaging and labeling is essential.</li></ul>

By implementing these strategies and fostering a culture of open communication and continuous improvement, healthcare organizations can create a safer environment for patients and minimize the risk of medication-related harm. The lessons learned from this near-tragedy serve as a reminder of the importance of vigilance, collaboration, and a commitment to patient safety at all levels of healthcare.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

Everything You Need To Know

1

What is hypernatremia and why was it significant in this case?

Hypernatremia, or dangerously high sodium levels, is a serious condition that can lead to severe health problems, as seen in the case of the 11-year-old boy. In this specific instance, hypernatremia was caused by a medication error where the boy received a sodium supplement five times more concentrated than prescribed. The implications of hypernatremia include reduced responsiveness, abnormal breathing, and cardiovascular compromise, as evidenced by the boy's critical condition upon hospital admission. The case demonstrates how a seemingly minor error in medication concentration can have life-threatening consequences.

2

What were the key factors that led to the medication error and what were the implications?

The critical factors that contributed to the medication error were the availability of sodium supplements in identical packaging but with different concentrations and the mix-up that occurred in the administration of the sodium supplement. In this instance, the 11-year-old boy received a sodium supplement that was five times more concentrated than prescribed. This highlights the need for clear labeling, pharmacist vigilance, and standardized concentrations to prevent similar incidents. Furthermore, the case underscores that medication errors are almost always multifactorial, involving multiple points of failure.

3

What were the initial medical findings and the boy's condition upon admission?

The boy's initial blood tests revealed dangerously high sodium levels (hypernatremia) at >200mmol/l, elevated chloride levels (hyperchloraemia), thrombocytopenia (low platelet count), and coagulopathy (impaired blood clotting). A chest X-ray confirmed pneumonia. He was initially admitted in critical condition with a Glasgow Coma Scale (GCS) score of 3, which necessitated immediate intubation and ventilation. These findings highlight the immediate and severe impact of the medication error, emphasizing the importance of correct diagnosis and immediate treatment.

4

How was the boy treated for the medication error?

The boy's treatment involved intensive care support, including careful correction of hypernatremia over four days, primarily with 0.9% sodium chloride. Intravenous potassium chloride infusions were used to address hypokalemia, which is a low potassium levels that can cause life-threatening arrhythmias. Other biochemical abnormalities gradually improved. The disseminated intravascular coagulation (DIC) improved with vitamin K therapy, and adrenaline support was weaned over five days. This approach underscores the importance of swift intervention and careful monitoring in managing such complex cases.

5

What key strategies can prevent similar medication errors from happening?

To prevent similar medication errors, a multi-faceted approach is necessary. This includes a combination of strategies such as clear labeling, pharmacist vigilance, and standardized concentrations. Clear labeling ensures that the correct medication and concentration are easily identifiable, while pharmacist vigilance helps to catch potential errors before they reach the patient. Standardized concentrations can also reduce the risk of mix-ups. By implementing these strategies, healthcare providers can significantly reduce the likelihood of medication errors and protect patients from harm.

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