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Tenfold medication dose prescribing errors.

Timothy S Lesar1

  • 1Albany Medical Center, Mail-code 85, 43 New Scotland Ave., Albany, New York 12208-3412, USA. lesart@mail.amc.edu

The Annals of Pharmacotherapy
|November 28, 2002
PubMed
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Tenfold medication dosing errors are common, especially in pediatrics, often due to decimal point or zero mistakes. Implementing safety processes can reduce these medication errors and prevent harm.

Area of Science:

  • Medical Safety
  • Pharmacology
  • Health Informatics

Background:

  • Medication dosing errors, specifically tenfold errors, pose a significant risk, particularly to pediatric patients.
  • Systematic evaluations of the characteristics and causes of these errors are limited.

Purpose of the Study:

  • To identify and quantify the characteristics of tenfold medication dosage prescribing errors.
  • To understand the contributing factors and potential impact of these errors.

Main Methods:

  • A retrospective evaluation of 200 consecutively detected medication orders with tenfold errors in dosing.
  • Analysis of error types, frequency, causes, enabling factors, and potential for adverse effects.

Main Results:

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  • Over an 18-month period, 200 tenfold prescribing errors were identified, with 61% being overdoses.
  • Pediatric patients accounted for 19.5% of errors, with levothyroxine, antimicrobials, cardiovascular, and central nervous system agents being common culprits.
  • Common causes included misplaced decimal points (43.5%), extra zeros (31.5%), and omitted zeros (25%).

    • Conclusions:

    • Tenfold medication dose errors are prevalent and linked to identifiable risk factors.
    • Standard medication safety protocols are likely effective in mitigating these risks.
    • This data is crucial for developing strategies to prevent adverse patient outcomes from medication errors.