Jade Hart and her son Max, who was almost given five times the prescribed dose of liquid steroid. Photo: Supplied / NZME
A mum has been left shaken after she almost gave her 2-year-old five times more liquid steroid than prescribed.
This comes after the Deputy Health and Disability Commissioner (HDC) released findings on Monday that outlined the same kind of incident, where a 4-week-old baby stopped breathing after being given the incorrect dose, because of a pharmacist error.
The mother performed CPR, and the baby survived but had to be admitted to hospital for treatment and observation.
Auckland mum Jade Hart said she was "in shock" when she read the findings on Monday, and realised how close she had come to the same experience.
She has now referred the matter to the HDC.
Her 2-year-old son Max, who is her "miracle baby" after 10 years of infertility which included rounds of IVF, three miscarriages, and a failed surrogacy journey, had developed ongoing issues with "viral-induced wheeze" - a common respiratory condition in children.
He had been admitted to Starship Children's Hospital many times, and his treatment had included the oral steroid prednisolone, also known as Redipred.
In March 2024, he was admitted to Starship and given a prescription for Redipred, which Hart's husband had collected.
But when she came to give the liquid to Max, Hart was surprised to see the dosage instructions.
"I looked on the box and it said 14ml and I was like, that is absolutely absurd," she said.
"I just knew it was incorrect straight away because I was like, even my eldest son, Leo, he's 7, there's no way he would even have that amount."
Hart's recollection was that Max was usually given "about 3ml" of the liquid, so she quickly rang the pharmacy to check.
"They were really good over the phone and they said, 'oh my God, we apologise so much'", she said.
Hart said the pharmacy explained that sometimes doctors' handwriting was hard to read, but they "fully accepted" they were in the wrong.
A letter of apology, seen by NZME, was sent to Hart from the pharmacy.
It explained that the 14mg dose, handwritten by a doctor, had been "interpreted as stating 14ml". The correct dose was 2.8ml.
These were the same circumstances as in the HDC findings - in that instance mg had been read as ml by a trainee technician, and the pharmacist failed to spot the mistake when handing the prescription to the baby's mother.
It had also been five times more than should have been prescribed - the baby should have been given just 0.9ml, but instead the dose read 4.5ml.
The HDC told NZME they'd had seven complaints containing the word 'Redipred'.
Of those complaints, three involved concerns related to incorrect dosage.
One of the complaints was referred to the provider for resolution with the consumer; one was closed with recommendations made to the provider; and another was closed with the provider having been found in breach of the Code of Health and Disability Services Consumers' Rights - that decision formed the basis for Monday's story.
Changes following Hart's complaint
After Hart contacted the pharmacy directly to query the dosage, they apologised and followed up with a letter that outlined the changes it had made to stop any incident like that from happening again.
This included increased training for pharmacy staff, specifically related to Redipred.
It also said pharmacists would now calculate the "expected weight" of a child, based on t
he dose prescribed. This would be checked against the "actual weight" of the child. If the weights didn't match, the pharmacist would take a closer look at the prescription, including contacting the prescriber if needed.
Learnings and training had been passed on to other pharmacies in its network.
Hart said she had been back to the pharmacy since the incident, having been prescribed Redipred again, and they had checked Max's weight.
"So I was really happy with that," she said.
After the incident, she asked the pharmacy what would have happened if the dose on the box had been given to her son and said they'd told her "he would have become really sick".
She hadn't thought much further, but having read that an overdose had caused a baby to stop breathing, she now considered that further investigation was needed, hence the referral to the HDC.
"I'm sure other people have been through similar things and ... when it's steroids, it is very important," she said.
She wanted to alert other parents to the fact that prescription doses could sometimes be wrong - she worries that her husband, who hadn't usually been the one to give the medication, wouldn't have had a reason to suspect an error if he'd been administering it.
"If you haven't been the parent that's been [giving the dose] ... [or you're] a parent who's new to being a parent with a newborn, sleep deprived, you have no idea how much, and you trust these people with your kid's life."
Given Hart has referred the incident to the HDC, NZME has chosen not to name the pharmacy, in light of what may be an active investigation.
The pharmacy was contacted for further comment but hadn't responded at the time of publication.
* This story first appeared in the New Zealand Herald.