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Abstract

We report a dispensing error involving a 2-year-old girl who presented with acute dystonic reaction following inadvertent over- dosage of an antipsychotic drug. She has three female full siblings, aged between four and nine years, who also had acute dystonic reaction simultaneously as the index case. Their mother had intended to purchase levamisole as a non-prescription, over-the-counter (OTC) drug to be used as an anti-helminthic, from a patent and proprietary medicine vendor (PPMV) but haloperidol was dispensed to her in error, which she ignorantly administered to all her four children. All four children developed acute dystonic reaction few hours after.
We considered this incidence of clinical and social importance because four children had haloperidol overdose (dose range between 10mg and 15mg) as a result of a medication error, and the possibility of more life-threatening complications and even death could only be imagined if the drug had been one with a narrow therapeutic index and/ or more fatal side effects. There is a need for better control and monitoring of the activities of retail drug outlets and dispensing of OTC drugs in Nigeria and other similar settings to forestall needless and potentially fatal consequences.

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