Top 10 Common Medication Errors -- Drug #7 -- Ciprofloxacin

A gastrostomy tube–dependent 5-year-old girl who weighed 20 kg presented with a 2-day history of fever and lethargy. Urine and blood samples were obtained for culture at that time. The patient was sent home without medication because the clinician thought that the patient might have a viral respiratory infection.

Two days later, the urine culture turned positive for Escherichia coli sensitive to only ciprofloxacin. The clinician thus called in a prescription to a local pharmacy for ciprofloxacin suspension (200 mg via G-tube bid [10 mg/kg/dose]). After the patient received 2 doses of the medication, the parents noticed that the G-tube was clogged off.

What’s the problem here?

Please click here for the answer and discussion.