Correspondence
Large Errors in the Dosing of Medications for Children
N Engl J Med 2002; 346:1175-1176April 11, 2002
- Article
To the Editor:
Dosing errors are among the most common types of medication errors.1-3 Errors by a factor of 10 (the administration of a dose 10 times or 1/10 as high as appropriate) are of particular concern.4 There is a greater chance that an infant or a young child will receive such a dose of medication than that an adult will, because even a dose 10 times as high as the appropriate pediatric dose may represent an unsuspiciously small volume of stock solution.
We reviewed all forms of errors involving medication that were reported to the pharmacy department at a large tertiary care pediatric hospital between April 1 and November 1, 2000. The hospital has a unit-dose system for dispensing drugs and a computerized system for prescribing medications. Twenty errors by a factor of 10 were spontaneously reported (1 per 22,500 doses). The errors involved 19 different medications. Most of these errors involved pharmacologically potent drugs, so that such an error could potentially result in death (in six cases), life-threatening toxic effects (in nine cases), or moderate toxic effects (in one case); in the remaining four cases, the error could not have resulted in toxic effects. Since many of the drugs are highly potent, they are usually given in doses of less than 1 mg per kilogram of body weight, creating a potential source of confusion during the conversion of milligrams to micrograms (Table 1Table 1
Medications Involved in Large Dosing Errors.). Most of the drugs were not among the 20 most commonly used medications in our hospital. Of the 20 incorrect doses, 5 reached the children (one newborn, one child 1.5 years of age, one 3.5 years of age, one 8 years of age, and one 12 years of age) and 15 were intercepted. Physicians were responsible for 18 of the 20 errors.To estimate the proportion of these large dosing errors that are reported spontaneously, we compared the rate of spontaneous reports from the emergency department with the rate of those found through audits of the charts in the emergency department for 12 randomly selected days. Two such errors were reported spontaneously by the emergency department (incidence, 1 per 13,000; 95 percent confidence interval, 0 to 3 per 10,000). The audits found 2 errors among 1532 charts (incidence, 1 per 766; 95 percent confidence interval, 13 to 47 per 10,000; P=0.005 for the comparison between the two methods of finding errors). The two errors found during the audits were not reported through the system for the spontaneous reporting of incidents. These findings suggest that spontaneous reports of large dosing errors in children may underestimate the true incidence.
The best strategy for reducing the incidence of large errors in dosing may be to improve the system by which drugs are given. Examples of such approaches are the use of a unit-dose system for dispensing drugs and the use of a computerized system for prescribing medications. However, most of the errors we found occurred despite the use of both of these types of systems, suggesting that the systems have limitations.
4 ReferencesEran Kozer, M.D.
Dennis Scolnik, M.B., Ch.B.
Tara Keays, B.Sc.H.
Kevin Shi, B.Sc.
Tracy Luk
Gideon Koren, M.D.
Hospital for Sick Children, Toronto, ON M5G 1X8, Canada1
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Guylaine Larose, Benoit Bailey, Denis Lebel. (2008) Quality of Orders for Medication in the Resuscitation Room of a Pediatric Emergency Department. Pediatric Emergency Care 24:9, 609-614
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David C. Kaelber, David W. Bates. (2007) Health information exchange and patient safety. Journal of Biomedical Informatics 40:6, S40-S45
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Eran Kozer, Dennis Scolnik, Anna D Jarvis, Gideon Koren. (2006) The Effect of Detection Approaches on the Reported Incidence of Tenfold Errors. Drug Safety 29:2, 169-174
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Ronda G. Hughes, Elizabeth A. Edgerton. (2005) Reducing Pediatric Medication Errors. AJN, American Journal of Nursing 105:5, 79-84
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Christopher S. Parshuram, Geraldine Y. T. Ng, Tommy K. L. Ho, Julia Klein, Aideen M. Moore, Desmond Bohn, Gideon Koren. (2003) Discrepancies between ordered and delivered concentrations of opiate infusions in critical care. Critical Care Medicine 31:10, 2483-2487
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T. B. Y. Liem. (2003) Voorschrijffouten: de oorzaken nader belicht. Medisch-Farmaceutische Mededelingen 41:1, 1-2
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Wood, Alastair J.J., , Berde, Charles B., Sethna, Navil F., . (2002) Analgesics for the Treatment of Pain in Children. New England Journal of Medicine 347:14, 1094-1103
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