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J Pediatr. 2005 Dec;147(6):761-7.

Potential medication dosing errors in outpatient pediatrics.

Author information

  • 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

Abstract

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.

PMID:
16356427
[PubMed - indexed for MEDLINE]
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