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Arch Pediatr Adolesc Med. 1998 Apr;152(4):340-4.

Errors in the use of medication dosage equations.

Author information

1
Department of Pharmacy, Albany Medical Center, NY 12208, USA. tlesar@ccgateway.amc.edu

Abstract

BACKGROUND:

Calculation errors in prescribing are a well-recognized problem; however, no systematic studies of actual errors involving calculation or other errors in the use of drug dosage equations are available.

OBJECTIVE:

To characterize the nature and potential adverse consequences of actual prescribing errors involving dosage equations.

DESIGN:

Analysis of the characteristics of 200 consecutive prescribing errors with potentially adverse outcomes involving dosage equations.

SETTING:

Tertiary care teaching hospital.

MEASUREMENTS:

Potential adverse outcomes, prescribing service, medication class, and the process point at which the error was made.

RESULTS:

Errors most commonly involved children (69.5%) and antibiotics (53.5%). Forty-two percent of errors were considered to put the patient at risk for a serious or severe preventable adverse outcome. Errors in decimal point placement, mathematical calculation, or expression of dosage regimen accounted for 59.5% of dosage errors. The dosage equation was wrong in 29.5% of dosage errors.

CONCLUSIONS:

The use of equations to determine medication dosages presents considerable risk to patients for errant dosing and subsequent adverse events or therapeutic failure. Errors may occur in any component of a dosage equation. Health care organizations should implement procedures to reduce the risk for errors resulting from the use of dosage equations.

PMID:
9559708
DOI:
10.1001/archpedi.152.4.340
[Indexed for MEDLINE]

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