Potential medication dosing errors in outpatient pediatrics
Meyers Primary Care Institute; Department of Medicine, Division of Geriatric Medicine; Department of Pediatrics
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.
The Journal of pediatrics
McPhillips HA, Stille CJ, Smith D, Hecht J, Pearson J, Stull J, DeBellis KR, Andrade SE, Miller M, Kaushal R, Gurwitz JH, Davis RL. (2005). Potential medication dosing errors in outpatient pediatrics. Meyers Primary Care Institute Publications. Retrieved from https://escholarship.umassmed.edu/meyers_pp/375