Potential Medication Dosing Errors in Outpatient Pediatrics

Tenfold errors in pediatric doses are not uncommon. Because the needed volume of stock solution is generally small, even a tenfold higher volume may still appear deceivingly normal. Such errors are much less likely to occur in adults, because it would result in unacceptably large volumes of stock solution. Other sources of tenfold errors are communication difficulties with parents and illegible writing of orders by physicians. Testing health professionals may identify subgroups of individuals who are prone to commit such errors. Independent double checking of calculations and a mechanism to resolve disagreement is being practiced in most academic institutions. Transition to patient's unit dose is likely to decrease calculation errors, because pharmacists commit fewer errors. Hazardous drugs that are not required on a stat basis should be removed from the wards.

Pediatric Medication Errors: Predicting and Preventing Tenfold Disasters

https://www.surgical.theclinics.com/article/S0039-6109(02)00007-5/pdf

Error and time delay in pediatric trauma resuscitation Addressing the problem with color-coded resuscitation aids

Evaluating the accuracy of electronic pediatric drug dosing rules

The inadvertent administration of drug doses greater than intended is not uncommon in the paediatric patient. These errors may arise from misunderstanding of the prescribed dose by the child’s caregiver or from mistakes of health professionals. Such errors have the potential to cause serious complications and their prevention is of paramount importance. Cyclosporin is an effective immunosuppressant which is most often used in organ transplantation; it is also used increasingly in non-transplant immunological and rheumatological conditions. The long term therapeutic use of cyclosporin is associated with several adverse effects, of which nephrotoxicity and hypertension are the most prominent.[1] Hepatotoxicity and CNS symptoms have also been described.[2-4] Human experience in the context of acute cyclosporin overdose is relatively limited and largely confined to adults.[5-11] Experience in children with accidental oral overdose is scarce.[12-14] The incidence of acute cyclosporin overdose in the paediatric population may increase as use of the drug increases. The objective of this article is to present a case of accidental oral overdose in an infant resulting from a 10-fold error in administration, and to highlight mechanisms and approaches for preventing such errors.

H. Zinman

Papers

Tenfold errors in drug dosage