A health outreach in Kabwangasi Town Council, Butebo District, turned tragic when 23 children were mistakenly given carbamazepine, an anticonvulsant medication, instead of mebendazole, used to treat worm infestations. The incident occurred during an Integrated Child Health Day outreach. The mix-up resulted in a two-year-old boy's death and 16 other children being admitted to Mbale Regional Referral Hospital with complications such as drowsiness and convulsions.
According to a situation report by the Mbale Region Emergency Operation Centre, each of the 23 children received five tablets of carbamazepine. The National Drug Authority (NDA) has since confirmed that the hospitalised children have stabilised and are expected to be discharged. NDA Manager for Pharmacovigilance, Julius Mayengo, revealed that a multidisciplinary committee of experts has been constituted to investigate the circumstances surrounding the medication error.
The committee is expected to release a scientific report by the end of the week. The Ministry of Health had dispatched a team of experts to Mbale and Butebo districts to establish how the incident occurred and identify measures to prevent a recurrence. The incident has been described as a medical error originating from healthcare workers involved in the outreach programme.
The Pharmaceutical Society of Uganda (PSU) has raised concerns over the recurrence of similar medication errors, revealing that a related incident was reported in March this year. PSU Secretary Dr Stephen Lutoti stated that the recurrence points to persistent weaknesses in medicine management and dispensing procedures during community health outreaches.
Lutoti called for the preservation of drug samples to facilitate independent verification, warning that carbamazepine poses significant toxicity risks, particularly among children. Seven children who received treatment at Kabwangasi Health Centre III had been discharged and were reported to be recovering well.
The NDA had previously stated that it was investigating the incident and would work with relevant stakeholders to prevent similar incidents in the future. The authority also urged healthcare workers to adhere to standard procedures when administering medication to patients.
The incident has highlighted the need for stricter quality control measures during health outreaches. Key stakeholders, including the Ministry of Health and the NDA, are expected to review their protocols to prevent similar incidents from occurring in the future.
Key points
- A two-year-old boy died as a result of the medication mix-up.
- The incident occurred during an Integrated Child Health Day outreach in Kabwangasi Town Council.
- A multidisciplinary committee has been constituted to investigate the circumstances surrounding the medication error.
