Patient got discharged from hospital on tacrolimus oral suspension (1 mg/1 ml) since he has ng tube.He received the medication without oral syringe from op pharmacy {due to lack of supply there).He was given insulin syringe on the floor to use.Patient's wife thought that 1 units in the insulin syringe = 1 ml leading to underdosing (patient ended up receiving 1/10th of the dose for around 2 weeks).Came back with decrease urine output and increase in creatinine.Dispensing device involved inappropriate / inaccurate measuring device.(b)(4).
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