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Medication Errors With Pediatric Liquid Acetaminophen After Standardization of Concentration and Packaging
Eric P Brass1, Kate M Reynolds2, Randy I Burnham2
1Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, Palos Verdes, Calif.
Insights
Changes to pediatric liquid acetaminophen packaging and concentration in 2011 reduced medication errors reported to poison control centers. Errors remain a concern for children under 2, highlighting the need for better dosing instructions.
Area of Science:
- Pediatric pharmacology
- Medication safety
- Public health
Background:
- Pediatric liquid acetaminophen has undergone packaging and concentration standardization.
- Medication errors involving pediatric medications are a significant public health concern.
Purpose of the Study:
- To evaluate the impact of 2011 packaging and concentration changes on acetaminophen-related medication errors in children.
- To assess trends in poison control center exposures before and after the 2011 product modifications.
Main Methods:
- Utilized National Poison Data System (NPDS) data from 2007-2016 for children under 12.
- Analyzed medication error exposures involving single-ingredient liquid acetaminophen.
- Conducted surveys via regional poison control centers for additional exposure details.
Main Results:
- Annual medication error exposures decreased by 19% (8260 to 6669) after 2011.
- Children under 2 years old accounted for 66% of exposures, with dosing information often unclear.
- Only 4% of exposures resulted in healthcare facility referrals.
Conclusions:
- Standardized acetaminophen concentration and packaging changes correlate with reduced medication errors.
- Dosing errors disproportionately affect young children (<2 years) due to lack of clear instructions.
- Enhanced caregiver education on pediatric acetaminophen dosing is recommended.
Objective:
To assess the impact of the 2011 changes in pediatric single-ingredient liquid acetaminophen product packaging and standardization of the acetaminophen concentration (160 mg/5 mL) on poison control center exposures due to medication errors.
Methods:
National Poison Data System (NPDS) data from January 1, 2007, through December 31, 2016, were used to identify medication error exposures involving single-ingredient liquid acetaminophen in children younger than 12 years of age. Surveys were conducted through 6 regional poison control centers to obtain additional information on a subset of exposures.
Results:
The annual frequency of NPDS exposures due to medication errors with single-ingredient liquid acetaminophen products was 8260 ± 670 exposures/year during 2007-2011. Children <2 years of age accounted for 66% of exposures. The overall rate of exposures fell to 6669 ± 662 during 2012-2016 (19% decrease; P = .005). Four percent of exposures led to health care facility referrals. Caregivers involved with exposures in children <2 years of age cited health professionals as the source of dosing information in only 69% of cases despite the absence of specific dosing directions for these children on product labels.
Conclusions:
Implementation of a single concentration for pediatric liquid acetaminophen products and packaging changes were associated with a decrease in medication errors reported to poison control centers. Medication errors are particularly problematic for children <2 years of age, for whom there are no specific labeled dosing instructions. Improved efforts to provide caregivers with dosing instructions for these children are encouraged.
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