A 13-month-old boy narrowly avoided being given an adult dosage of cough syrup after a clinic allegedly mixed up his prescription with another patient’s.
The child’s mother, who goes by @iiiviiixivii on social media, shared the incident online to warn other parents to always check their children’s medication before administering it.
She said her son had been taken to a clinic in Putra Heights by her brother-in-law and his wife after developing a fever, cough, runny nose and flu-like symptoms. The doctor prescribed several medications, which were taken home.
The following day, while preparing to give her son his medicine, she noticed that one bottle of cough syrup instructed him to take 7.5ml per dose. However, the packaging stated that the recommended dosage for a child of his age was only 2.5ml.
“I kept wondering if 7.5ml was really the correct dose for a 13-month-old. It just didn’t seem right,” she said.
She immediately contacted the clinic, where staff admitted that her son and her brother-in-law had visited at the same time and their prescriptions had been accidentally switched. The clinic apologised for the mistake.
Although the medicine bottle was labelled with the baby’s name, the 7.5ml dosage had actually been prescribed for the child’s adult uncle.
The mother said she could not stop thinking about what might have happened if she had trusted the label without checking the medication instructions first.
She hopes the incident will encourage the clinic to review its prescribing, dispensing and labelling procedures, including introducing a stricter double-check system to prevent similar mistakes.
While acknowledging that healthcare workers can make mistakes, she stressed that an error at any stage—from prescribing and dispensing to labelling—could put patients, especially young children, at unnecessary risk.
She also urged parents to verify the medication name, dosage and instructions every time before giving medicine to their children, and to consult a doctor or pharmacist immediately if anything appears unusual or unclear.
