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Potential medication dosing errors in outpatient pediatrics
Heather A McPhillips1, Christopher J Stille, David Smith
1Department of Pediatrics and Epidemiology, University of Washington, and the Center for Health Studies, Group Health Cooperative, Seattle, Washington, 98105, USA. heather.mcphillips@seattlechildrens.org
Insights
Approximately 15% of children receive medications with potential dosing errors, including overdoses and underdoses. Further research is needed to understand the clinical impact and develop prevention strategies for pediatric medication safety.
Area of Science:
- Pediatric Pharmacology
- Medication Safety
- Health Services Research
Background:
- Medication dosing errors in children can lead to adverse health outcomes.
- Accurate medication dispensing is crucial for pediatric patient safety.
Purpose of the Study:
- To determine the prevalence of potential medication dosing errors in children.
- To assess dosing errors for 22 common pediatric medications.
Main Methods:
- Analysis of automated pharmacy data from 3 health maintenance organizations (HMOs).
- Inclusion of 1933 pediatric subjects with new dispensing prescriptions.
- Comparison of error rates between paper and electronic prescription systems.
Main Results:
- 15% of children received medications with potential dosing errors (8% overdose, 7% underdose).
- Children under 35 kg had only 67% of doses within recommended ranges.
- Analgesics were most frequently overdosed (15%), while antiepileptics were most underdosed (20%).
- Electronic prescribing did not reduce error rates.
Conclusions:
- Potential medication dosing errors are common in outpatient pediatric settings.
- Further studies are required to evaluate the clinical significance of these errors.
- Effective strategies for preventing pediatric medication dosing errors need to be developed.
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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