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Top 10 Common Medication Errors—Drug #9: Clonidine

Top 10 Common Medication Errors—Drug #9: Clonidine

A 1-month-old boy (weight, 5 kg) was prescribed clonidine (5 mg [1 mg/kg/dose] PO q8h) for neonatal abstinence syndrome. His parents filled this prescription at a local pharmacy. After taking a few doses of the medication, the boy became extremely lethargic. He was seen at the clinic and was found to be hypotensive and was admitted to a nearby hospital.

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