One-month-old baby overdoses on heart medication after error by Port Augusta doctor

At just one month old, Jacob Barlow took ten times the amount of his new heart medication after a doctor misplaced a decimal. Only his mum’s quick thinking saved him.

Jacob Barlow, right, who overdosed on heart medication, with his mum Rachel, dad Kane and sister Isabella. Picture: Supplied by family

A one-month-old baby with Down syndrome could have lost his life after a doctor at a rural hospital prescribed him medication 10 times higher than the required dosage.

The dose caused Jacob Barlow to overdose and sparked change to Port Augusta Hospital’s protocols.

Now his mother Rachel Barlow is calling for community pharmacies to change its protocols after Donald Mudge suffered an almost fatal overdose a week ago.

In March 2011, the doctor accidentally placed the decimal in the wrong spot when prescribing Jacob with Lasix – a medication that causes you to urinate more than the norm.

Baby Jacob urinated so much he could’ve died.

“It was terrifying … very scary, very traumatic,” the Whyalla mum said.

Even the pharmacist dispensing Jacob’s new medication had to remove the syringe that originally came with the medication to replace it with a larger one, which they later admitted was a red flag.

Jacob Barlow with his dad Kane Barlow in hospital recovering from the overdose. Picture: Supplied by family

Jacob Barlow, who made a full recovery and forced changes at Port Augusta hospital, with his mum Rachel, dad Kane and sister Isabella. Picture: Supplied by family

Luckily Ms Barlow noticed something was wrong and called Jacob’s doctor before rushing to the hospital where medical professionals treated the boy.

Since the heartbreaking situation, the Port Augusta Hospital changed its practices to ensure prescriptions are double-checked.

“It was a case of two human errors,” the 40-year-old mum said.

“The next day the pharmacist and the pediatrician apologised.

“They said they would put things in place and they were really sorry.”

After leaving the hospital with the incorrect dosage, Ms Barlow and Jacob arrived back in their home town of Whyalla.

“We tried to give a one-month-old baby 10mls of Lasix and really struggled,” Ms Barlow, who is Whyalla’s Citizen of the Year, said.

“I was saying to the baby ‘you need to have this, this is going to make you better’.”

When out shopping the now mum-of-two noticed Jacob urinated through his nappy.

“I put the nappy in a snap lock bag and decided to call the doctor,” Ms Barlow said.
She said she knew the medication was a diuretic and she was expecting Jacob to urinate more than usual but she said this amount felt “extreme”.

Jacob Barlow, who is now 12, overdosed on heart medication when he was a month old. Picture: Supplied by family

Jacob’s overdose came a few weeks after suffering with a blood and kidney infection when he was only five days old. He was barely home when doctors discovered he had a heart condition.

“To go from, he’s got a heart condition, to he needs this medication that’s quite severe, to you’ve just given him 10 times the amount of the medication … and he might just pee himself to death, it’s really stressful,” Ms Barlow said.

Ms Barlow said she thinks of the incident every time she gives her children medication and that it has made her stronger.

“It made me realise that I have to follow my gut because if I hadn’t followed my gut that day he would’ve probably passed,” she said.

Ms Barlow said she wants to see the changes across all pharmacies.

“We’re proud to know that they made changes because of what happened to our son which was an understandable mistake,” she said.

“People make mistakes, we get that and don’t hate anyone, we have no anger towards anyone.

“But we’re really glad that our son’s made a difference … every time a child is given medication in that hospital, they’re safer because of what happened to Jacob.

“I’d love to see that in community pharmacies.”

The Advertiser understands there have been no other incidents of pediatric medication being wrongly prescribed since at Port Augusta Hospital.

For many years at the hospital two pharmacists have been required to confirm pediatric prescriptions.