Kalyan, Maharashtra—August 26, 2025 – A ten-year-old boy in Kalyan, Maharashtra, who had been diagnosed with typhoid and pneumonia, was mistakenly prescribed medications used to manage type 2 diabetes and angina. The case occurred at Manomi Multi Speciality Hospital near Aadharwadi Chowk, where two separate prescription pages were issued—one listing appropriate typhoid drugs, and another listing Sitagliptin Phosphate and Metformin Hydrochloride (diabetes drugs) alongside St Sprin 75 (used to prevent heart-related conditions).
The error came to light when the boy’s mother, Ankita Ravi Gaikwad, consulted another doctor for a follow-up injection and discovered that the prescribed medicines were not meant for typhoid or pneumonia. She then raised her concern with the original doctor, who initially affirmed the prescription. Hospital management later confirmed the mistake and informed the family, advising them not to administer the erroneous drugs.
According to Dr. Sunny Singh, the mix-up occurred because Dr. Rusha, who handled the boy’s case, was simultaneously attending to another patient and inadvertently mixed up the prescriptions. The hospital notified the family as soon as the error was identified. The family plans to file a legal case in response.
The incident was publicly disclosed on August 26, 2025 by an NDTV report.
1. Eight-Month-Old in Kerala Ended Up in Intensive Care
In March 2025, an eight-month-old baby in Kannur, Kerala, was administered drops instead of a prescribed syrup for fever. The pharmacy’s substitution led to severe liver damage and critical condition. The error was reported to the police, and a formal investigation was launched against the pharmacy.
2. Four-Year-Old in Tripura Hospitalized After Wrong Antibiotic
In October 2024, a four-year-old in Agartala, Tripura, was hospitalized after being given the incorrect medication due to misreading the doctor’s prescription. The drug store staff administered a high dose antibiotic on an empty stomach, beyond what was intended. The staff member acknowledged difficulty in reading the handwritten prescription.
3. India-Wide Risk from Look-Alike Packaging
There are documented cases in India of severe outcomes when medications look alike. For example, in one case reported by Pubtexto, a 9-month-old infant was given metoclopramide suppositories instead of paracetamol due to similar packaging and reliance on color rather than clear labeling. The infant experienced dizziness and unusual oral sensations but recovered fully after receiving correct treatment.
Another case reported by TOI involved an oral rehydration solution. A child prescribed pediatric ORS was given adult ORS because the doctor failed to specify the formulation. The parents followed the instructions and administered it as directed, resulting in seizures, kidney failure, and death.
Drugs like Sitagliptin Phosphate and Metformin Hydrochloride, typically prescribed for adults with type 2 diabetes, and St Sprin 75, used to prevent blood clots in adults with heart disease, can be harmful if given to children without medical need.
Diabetes drugs: Sitagliptin and Metformin affect blood sugar regulation. In children without diabetes, these drugs can cause dangerous hypoglycemia, nausea, vomiting, and lactic acidosis, a serious condition where acid builds up in the body. [1]
Aspirin in children: Low-dose aspirin is sometimes used in pediatric cardiology under strict supervision. However, giving aspirin without indication can increase the risk of Reye’s syndrome, a rare but potentially fatal condition that causes liver and brain damage in children recovering from viral infections. [2]
Unnecessary drug exposure: Children’s livers and kidneys process drugs differently from adults. Unindicated medications can overload these organs, leading to toxicity or long-term health effects. [3]
Experts say that these cases highlight the vulnerabilities in prescription, dispensing, and administration processes in pediatric care. Critics suggest that errors can range from confusion due to handwriting to hazards posed by look-alike packaging and ensuring safety requires diligence from healthcare providers, pharmacists, and caregivers.
References:
MedlinePlus, “Diazepam (Oral Route),” MedlinePlus, accessed August 27, 2025. https://medlineplus.gov/druginfo/meds/a696005.html.
Centers for Disease Control and Prevention (CDC), “Editorial Note: Trends in Drug–Related Deaths — United States, 1979–1996,” Morbidity and Mortality Weekly Report, accessed August 27, 2025. https://www.cdc.gov/mmwr/preview/mmwrhtml/00001108.htm.
World Health Organization, Pocket Book of Hospital Care for Children: Guidelines for the Management of Common Childhood Illnesses (2nd ed.; Geneva: World Health Organization, 2013). https://apps.who.int/iris/bitstream/10665/81170/1/9789241548373_eng.pdf
(Rh/Eth/MSM)