Potential medication dosing errors in outpatient pediatrics

UMMS Affiliation

Meyers Primary Care Institute; Department of Medicine, Division of Geriatric Medicine; Department of Pediatrics

Publication Date


Document Type



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.


J Pediatr. 2005 Dec;147(6):761-7.

Journal/Book/Conference Title

The Journal of pediatrics

Related Resources

Link to article in PubMed

PubMed ID