Mistake by a compounding pharmacy investigated by Tennessee Board of Pharmacy--PIC mistakenly used hydrocodone powder to compound 4 -year-old medication for azithromycin gets a letter of warning from the board even though pharmacy had prior discipline record

20. Complaint alleges a 4-year-old child’s medication order for compounded azithromycin was incorrectly filled with hydrocodone. Child was admitted to hospital for treatment but recovered. Lab tests confirmed the presence of hydrocodone. BOP investigator visited the pharmacy and PIC. Respondent PIC admitted to mistakenly using hydrocodone powder to compound the medication and stated that they have now instituted a policy of prohibiting more than one drug in the area where compounding is being conducted. Prior Discipline: The pharmacy agreed to pay $190 for out of date drugs in September 2014. Recommendation: LOW to PIC for misfill and for failure to notify BOP (1140-03-.14 (14))

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