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Case Report

A previously healthy 10-month-old girl was taken to a pediatrician's office by her monolingual Spanish-speaking parents when they noted that their daughter had generalized weakness. The infant was diagnosed with iron-deficiency anemia. At the time of the clinic visit, there were no Spanish-speaking staff or interpreters available. One of the nurses spoke broken Spanish and in general terms was able to explain the girl had "low blood" and needed to take a medication.

The parents were thankful for the attention and nodded in understanding. The pediatrician wrote the following prescription in English:

Fer-Gen-Sol iron, 15 mg per 0.6 ml, 1.2 ml daily (3.5 mg/kg)

The parents took the prescription to the pharmacy. The local pharmacy did not have a Spanish-speaking pharmacist on staff, nor did they obtain an interpreter. The pharmacist attempted to demonstrate proper dosing and administration using the medication dropper and the parents nodded in understanding. The prescription label on the bottle was written in English.

The parents administered the medication at home and, within 15 minutes, the 10-month-old vomited twice and appeared ill. They took her to the nearest emergency department, where the serum iron level 1 hour after ingestion was found to be 365 mcg/dL (therapeutic levels are 60-180 mcg/dL). She was admitted to the hospital for intravenous hydration and observation. Serial serum iron levels and electrolytes were monitored. She was asymptomatic for the remainder of the hospitalization and discharged the following day with no apparent sequelae.

Upon questioning, the parents stated that they had administered a household tablespoon of the medication, approximately 15 ml or 43 mg/kg (a 12.5-fold overdose). At the time of discharge from the hospital, the nurse counseled the parents on proper dosing through a hospital interpreter.

-- Agency for Healthcare Research and Quality
Used with permission.