Potential medication dosing errors in outpatient pediatrics
Meyers Primary Care Institute; Department of Medicine, Division of Geriatric Medicine; Department of Pediatrics
Medical Subject Headings
Adolescent; Ambulatory Care; Child; Child, Preschool; Drug Prescriptions; Female; Health Maintenance Organizations; Humans; Infant; Infant, Newborn; Logistic Models; Male; Medication Errors; Medication Systems; Pediatrics; Retrospective Studies; Risk Factors; United States
Health Services Research | Pediatrics | Primary Care
OBJECTIVE: To determine the prevalence of potential dosing errors of medication dispensed to children for 22 common medications.
STUDY DESIGN: Using automated pharmacy data from 3 health maintenance organizations (HMOs), we randomly selected up to 120 children with a new dispensing prescription for each drug of interest, giving 1933 study subjects. Errors were defined as potential overdoses or potential underdoses. Error rate in 2 HMOs that use paper prescriptions was compared with 1 HMO that uses an electronic prescription writer.
RESULTS: Approximately 15% of children were dispensed a medication with a potential dosing error: 8% were potential overdoses and 7% were potential underdoses. Among children weighing <35 >kg, only 67% of doses were dispensed within recommended dosing ranges, and more than 1% were dispensed at more than twice the recommended maximum dose. Analgesics were most likely to be potentially overdosed (15%), whereas antiepileptics were most likely potentially underdosed (20%). Potential error rates were not lower at the site with an electronic prescription writer.
CONCLUSIONS: Potential medication dosing errors occur frequently in outpatient pediatrics. Studies on the clinical impact of these potential errors and effective error prevention strategies are needed.
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Citation: J Pediatr. 2005 Dec;147(6):761-7.
McPhillips, Heather A.; Stille, Christopher J.; Smith, David; Hecht, Julia; Pearson, John; Stull, John; DeBellis, Kristin R.; Andrade, Susan E.; Miller, Marlene; Kaushal, Rainu; Gurwitz, Jerry H.; and Davis, Robert L., "Potential medication dosing errors in outpatient pediatrics" (2005). Meyers Primary Care Institute Publications and Presentations. Paper 375.