{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,8,26]],"date-time":"2025-08-26T00:14:29Z","timestamp":1756167269698,"version":"3.44.0"},"reference-count":22,"publisher":"BMJ","issue":"8","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2025,8,11]]},"published-print":{"date-parts":[[2025,8]]},"abstract":"<jats:p>An early childhood male (2\u20135 years) who was prescribed clonidine presented to the emergency department with altered mental status, bradycardia and hypertension after an accidental clonidine overdose traced to a pharmacy compounding error. The patient was admitted to the paediatric intensive care unit and developed paralytic ileus, which necessitated nasogastric tube placement. An investigation by the State Board of Pharmacy revealed that the error involved the use of clonidine powder instead of tablets during the compounding process, which resulted in a 1000-fold overdose. This case highlights key historical details a clinician should elicit to assess the likelihood of a compounding error. We outline here important steps for investigation and management when such an error is suspected.<\/jats:p>","DOI":"10.1136\/bcr-2025-266965","type":"journal-article","created":{"date-parts":[[2025,8,25]],"date-time":"2025-08-25T19:05:25Z","timestamp":1756148725000},"page":"e266965","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Massive clonidine overdose in a paediatric patient due to a pharmacy compounding error and a primer on investigating suspected compounding errors"],"prefix":"10.1136","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7950-6762","authenticated-orcid":false,"given":"Brian Patrick","family":"Murray","sequence":"first","affiliation":[{"name":"Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, Ohio, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-7608-4201","authenticated-orcid":false,"given":"Matthew David","family":"Sheridan","sequence":"additional","affiliation":[{"name":"Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, Ohio, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-5643-829X","authenticated-orcid":false,"given":"Hannah","family":"Hays","sequence":"additional","affiliation":[{"name":"Toxicology, Central Ohio Poison Center, Nationwide Children\u2019s Hospital, Columbus, Ohio, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,8,25]]},"reference":[{"key":"2025082512051964000_18.8.e266965.1","article-title":"Pediatric Compounding Pharmacy: Taking on the Responsibility of Providing Quality Customized Prescriptions","volume":"6","author":"Heitman","year":"2019","journal-title":"Children (Basel)"},{"key":"2025082512051964000_18.8.e266965.2","doi-asserted-by":"crossref","DOI":"10.3390\/ph15091091","article-title":"The Role of Pharmaceutical Compounding in Promoting Medication Adherence","volume":"15","author":"Carvalho","year":"2022","journal-title":"Pharmaceuticals (Basel)"},{"key":"2025082512051964000_18.8.e266965.3","doi-asserted-by":"publisher","DOI":"10.1001\/archpedi.156.4.392"},{"key":"2025082512051964000_18.8.e266965.4","doi-asserted-by":"crossref","first-page":"531","DOI":"10.1007\/s40263-013-0084-8","article-title":"Overdose of drugs for attention-deficit hyperactivity disorder: clinical presentation, mechanisms of toxicity, and management","volume":"27","author":"Spiller","year":"2013","journal-title":"CNS Drugs"},{"key":"2025082512051964000_18.8.e266965.5","doi-asserted-by":"crossref","first-page":"362","DOI":"10.1089\/cap.2014.0122","article-title":"Changing patterns of alpha agonist medication use in children and adolescents 2009-2011","volume":"25","author":"Fiks","year":"2015","journal-title":"J Child Adolesc Psychopharmacol"},{"key":"2025082512051964000_18.8.e266965.6","doi-asserted-by":"publisher","DOI":"10.1136\/archdischild-2018-316026"},{"key":"2025082512051964000_18.8.e266965.7","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpeds.2013.08.038"},{"key":"2025082512051964000_18.8.e266965.8","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1186\/s12245-019-0231-1","article-title":"Outcomes following clonidine ingestions in children: an analysis of poison control center data","volume":"12","author":"Amico","year":"2019","journal-title":"Int J Emerg Med"},{"key":"2025082512051964000_18.8.e266965.9","doi-asserted-by":"publisher","DOI":"10.1007\/s13181-020-00814-3"},{"key":"2025082512051964000_18.8.e266965.10","doi-asserted-by":"publisher","DOI":"10.1542\/peds.108.2.471"},{"key":"2025082512051964000_18.8.e266965.11","doi-asserted-by":"crossref","first-page":"295","DOI":"10.1097\/00006565-200208000-00014","article-title":"Pediatric clonidine poisoning as a result of pharmacy compounding error","volume":"18","author":"Suchard","year":"2002","journal-title":"Pediatr Emerg Care"},{"key":"2025082512051964000_18.8.e266965.12","doi-asserted-by":"crossref","first-page":"130","DOI":"10.1007\/BF03161223","article-title":"Toxicity from a clonidine suspension","volume":"5","author":"Farooqi","year":"2009","journal-title":"J Med Toxicol"},{"key":"2025082512051964000_18.8.e266965.13","first-page":"596","article-title":"Prolonged hypertension from a 1,000 fold clonidine compounding error. In: 2013 Annual Meeting of the North American Congress of Clinical Toxicology (NACCT)","volume":"51","author":"Biary","year":"2013","journal-title":"Clin Toxicol"},{"key":"2025082512051964000_18.8.e266965.14","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1016\/j.jemermed.2020.04.027","article-title":"Clonidine Compounding Error: Bradycardia and Sedation in a Pediatric Patient","volume":"59","author":"Barbuto","year":"2020","journal-title":"J Emerg Med"},{"key":"2025082512051964000_18.8.e266965.15","doi-asserted-by":"publisher","DOI":"10.1016\/j.mcna.2008.01.002"},{"key":"2025082512051964000_18.8.e266965.16","doi-asserted-by":"crossref","DOI":"10.1002\/ams2.573","article-title":"Perspectives on paralytic ileus","volume":"7","author":"Weledji","year":"2020","journal-title":"Acute Med Surg"},{"key":"2025082512051964000_18.8.e266965.17","doi-asserted-by":"publisher","DOI":"10.1007\/BF02555027"},{"key":"2025082512051964000_18.8.e266965.18","doi-asserted-by":"publisher","DOI":"10.1016\/j.bpg.2007.03.001"},{"key":"2025082512051964000_18.8.e266965.19","doi-asserted-by":"publisher","DOI":"10.1007\/s001340050409"},{"key":"2025082512051964000_18.8.e266965.20","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.1.6012.769-c","article-title":"Letter: Pseudo-obstruction due to clonidine","volume":"1","author":"Bauer","year":"1976","journal-title":"Br Med J"},{"key":"2025082512051964000_18.8.e266965.21","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.1.6003.197","article-title":"Pseudo-obstruction due to clonidine","volume":"1","author":"Bear","year":"1976","journal-title":"Br Med J"},{"key":"2025082512051964000_18.8.e266965.22","doi-asserted-by":"crossref","DOI":"10.1016\/j.ijpharm.2024.124169","article-title":"Exploring paediatric oral suspension development: Challenges, requirements, and formulation advancements","volume":"657","author":"Gaikwad","year":"2024","journal-title":"Int J Pharm"}],"container-title":["BMJ Case Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bcr-2025-266965","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,25]],"date-time":"2025-08-25T19:05:27Z","timestamp":1756148727000},"score":1,"resource":{"primary":{"URL":"https:\/\/casereports.bmj.com\/lookup\/doi\/10.1136\/bcr-2025-266965"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,8]]},"references-count":22,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2025,8,25]]},"published-print":{"date-parts":[[2025,8]]}},"alternative-id":["10.1136\/bcr-2025-266965"],"URL":"https:\/\/doi.org\/10.1136\/bcr-2025-266965","relation":{},"ISSN":["1757-790X"],"issn-type":[{"value":"1757-790X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,8]]}}}