Augmentin, a DAW Notation, and a Closed Prescriber's Office

No. This is not a substitution the pharmacist may make on his or her own authority.

• Generic substitution in Massachusetts is limited to the same drug, same dosage form, and same strength as the prescription - the interchangeable, therapeutically equivalent product. 400/57 and 600/42 are different amoxicillin-to-clavulanate ratios, not AB-rated equivalents, and the dosing implications differ (the 600/42 product delivers more amoxicillin and less clavulanate per 5 mL).
• Choosing the 600/42 product would be a therapeutic interchange, which requires prescriber authorization - a new prescription or a documented verbal order.
• The "DAW" notation reinforces the point: the prescriber has directed no substitution, and it also governs any generic substitution the pharmacist might otherwise make for a brand product.
• Correct steps: call the prescriber's on-call line, document the conversation (drug, strength, new directions, prescriber name, time, and your name), or identify a nearby pharmacy holding the 400/57 product and arrange a transfer with the mother's authorization. Holding the child's antibiotic overnight when an alternative exists is a poor outcome; dispensing the wrong strength is worse.

The label is incomplete for a pediatric suspension and the auxiliary sticker is misleading as written.

• The prescription label must show the pharmacy name and address, prescription number, date, patient name, prescriber, drug name and strength, quantity, and complete directions. "Take 5 mL twice daily" is acceptable only if it matches the prescription exactly; the pharmacist must verify it against the original, not the technician's transcription.
• Reconstitution and storage: the powder must be reconstituted with water, shaken well, and the resulting suspension refrigerated and discarded after 10 days (per the manufacturer's labeling). "Refrigerate" alone does not tell the parent to discard the remainder, which is the safety-critical instruction here.
• The pharmacist must orally counsel, at minimum: shake well before each dose, use the measuring device, complete the full 10 days even after the fever resolves, refrigerate and discard after 10 days, and watch for diarrhea, rash, or worsening illness.
• Document that counseling was offered and whether it was accepted or declined. An offer to counsel is required; a signature capturing refusal is the record that protects the pharmacist.

Prioritize a correct, timely antibiotic over speed, and narrate the plan to the mother.

1. Start the call now: urgent care on-call line for authorization to dispense 600/42 with recalculated directions, or a new prescription. If unreachable, call the pharmacy's other locations and outside pharmacies to locate 400/57.
2. Do not dispense the non-equivalent strength while waiting, and do not "split the difference" with a calculated dose of the 600/42 product under the existing prescription - that is a new prescription.
3. Give the mother options and a timeline: await the callback, transfer the prescription to a pharmacy with stock (a non-controlled prescription may be transferred on her authorization, with documentation), or return to urgent care.
4. Address the fever and red flags: advise on weight-based antipyretic dosing, hydration, and when to seek emergency care (lethargy, stiff neck, breathing difficulty, no improvement in 48–72 hours).
5. Document everything: the non-equivalent product problem, the attempted contacts, times, the plan chosen, and the counseling provided.