Anaphylactic reaction secondary to a medication administration error in a patient receiving intravenous antibiotics.

: The occurrence of either medication administration errors or adverse drug reactions (ADRs) in hospitalized patients are well documented events. The combination of the two sequelae to drug therapies can lead to potentially life threatening episodes. In the case reported here, a medication administration error led to an ADR which threatened the life of a 12-month-old boy. The patient was receiving doses of cefotaxime sodium and nafcillin sodium, and was inadvertently administered a dose of cefoxitin sodium through a nursing staff medication administration errors. The patient experienced marked flushing; pitting edema, tachycardia, and a rapid respiration rate. Wheezing was absent. The patient recovered spontaneously after discontinuance of the inappropriately administered cefoxitin sodium dose, and discontinuance of cefotaxime sodium as well. Pharmacists must remain diligent in the review of the drug use process in institutions. Appropriate reconstitution, labeling, and dispensing of prescribed IV medications does not necessarily lead to appropriate administration of the drug. Pharmacy staff reviewal of the medication administration process must be carried out in conjunction with the nursing staff to ensure appropriate drug use. Patient and professional alike will benefit from such actions.