Top 10 Common Medication Errors-Drug #8: Carbamazepine
April 29, 2013
A 9-kg 15-month-old girl with new-onset generalized tonic-clonic seizure was discharged with instructions to take carbamazepine suspension (45 mg PO BID [10 mg/kg/d]), which she'd been receiving in the hospital. In the clinic, her carbamazepine blood level was subtherapeutic. The dose was increased to 68 mg PO BID. A week later, the carbamazepine level was still subtherapeutic, but no doses had been missed. What’s the problem here?