Remember "One Shake, Two Shake" With Reconstituted Oral Meds

Mishaps with oral powders for reconstitution can lead to overdoses or treatment failures.

In a recent case, an 8-month-old child was given a dose of unmixed amoxicillin/clavulanate. The patient was taken to the ED for an overdose because the unreconstituted powder is very concentrated.

In another case, a Suprax suspension was mixed with the wrong amount of water because the reconstitution directions were misread as "add 33 mL two TIMES"...instead of "add 33 mL in two PORTIONS."

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