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Clin Toxicol (Phila). 2009 Apr;47(4):348-54. doi: 10.1080/15563650902897650.

Severe injury or death in young children from therapeutic errors: a summary of 238 cases from the American Association of Poison Control Centers.

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Cincinnati Children's Hospital Medical Center and Division of Emergency Medicine, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA.



Medication-related errors pose a risk to children, but accurate data regarding errors with clinically significant outcomes are not available. We attempt to describe errors, identify patterns of error, and find targets for prevention using a large series of pediatric therapeutic errors with severe outcomes.


A national, retrospective poison center chart review study including all cases of severe injury or death from therapeutic error involving children less than 6 years which were reported to the American Association of Poison Control Centers from 2000-2004 was performed.


Among 272 cases identified, 238 were included in analysis and 34 were excluded; 162 cases occurred in the home and 70 in health care facilities. Significant errors disproportionately affected children less than 1 year (107/238 cases, 45%). The majority of errors were due to excessive dosing (171/238, 72%). Common mechanisms of error were identified: 10-fold errors, confusion about formulation or units of measure, increased frequency, and adult dosing.


The recurring circumstances underlying many of these errors suggest that preventing such errors may require systemic/process changes.

[Indexed for MEDLINE]

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