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Medication Mix-Up Causes Adverse Effects in Newborns

David W. Hodges
Partner at Kennedy Hodges LLP practicing pharmacy error, medical malpractice and personal injury law
Posted on Mar 07, 2013

Recently, a case was reported of an infant who suffered the fatal effects of receiving the wrong medication, methylergonovine maleate, at the hospital. According to reports, several cases have occurred in which a drug intended for an infant’s mother was given to the newborn instead.

Why is this happening?

According to reports, some medications for adults look or sound similar to pediatric drugs. This is the case with methylergonovine maleate, a drug used to manage postpartum atony, hemorrhage, and subinvolutin. Methylergonovine maleate looks similar to a hepatitis B vaccine given to infants, and its branded version, Methergine, has been confused with a similar-sounding medication, Brethine. Additionally, medication mistakes occur because this drug meant for mothers is generally kept close to the hepatitis vaccine, Engerix-B, which is meant for infants. In fact, sometimes the medications are brought into the nursing room at the same time, which increases the chances of a mix-up.

When a baby receives this adult drug by mistake, the infant can suffer from respiratory depression, cyanosis, oliguria, hypothermia, hypertonicity, and seizures. According to American Regent, the manufacturer of the generic version of methylergonovine maleate, an infant can die of toxic doses of this medication. For this reason, American Regent sent out a “Dear Healthcare Professional” letter warning healthcare professionals that “death may result from ergot-associated respiratory depression.”

Dr. Cohen, who has reported cases of this drug mix-up, has outlined some preventive measures, including:

  • Make sure the injectable pediatric medications are kept separate from methylergonovine maleate.
  • Design separate areas for newborn and mother medications.
  • Apply a label to the medication to remind healthcare professionals of the danger.
  • Administer newborn medication outside of the birthing area to prevent this mix-up.

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