Medication errors can cause various complications and some of these are fatal also. A very unusual complication, an esophageal foreign body, is described herein. It was a single tablet with intact wrapper, cut out from a blister pack which was unknowingly ingested by a child in toto. She was not instructed properly regarding administration of the drug. The peculiarity of this case concerns the type, location of the foreign body and need of clear instructions to be given to the patient for taking a medication.
Keywords: endoscopy; esophageal foreign body; medication error.