title: Potential medication dosing errors in outpatient pediatrics.
abstract: OBJECTIVE
  To determine the prevalence of potential dosing errors of medication dispensed to children for 22 common medications.
  
  
  METHODS
  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.
authors.affiliation: Department of Pediatrics and Epidemiology, University of Washington, and the Center for Health Studies, Group Health Cooperative, Seattle, Washington, 98105, USA. heather.mcphillips@seattlechildrens.org
authors.forename: Heather A
authors.initials: HA
authors.lastname: McPhillips
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Stille
authors.forename: David
authors.initials: D
authors.lastname: Smith
authors.forename: Julia
authors.initials: J
authors.lastname: Hecht
authors.forename: John
authors.initials: J
authors.lastname: Pearson
authors.forename: John
authors.initials: J
authors.lastname: Stull
authors.forename: Kristin
authors.initials: K
authors.lastname: Debellis
authors.forename: Susan
authors.initials: S
authors.lastname: Andrade
authors.forename: Marlene
authors.initials: M
authors.lastname: Miller
authors.forename: Rainu
authors.initials: R
authors.lastname: Kaushal
authors.forename: Jerry
authors.initials: J
authors.lastname: Gurwitz
authors.forename: Robert L
authors.initials: RL
authors.lastname: Davis
mesh_terms: D000293:Adolescent; D000553:Ambulatory Care / Q000592:standards*; D002648:Child; D002675:Child, Preschool; D011307:Drug Prescriptions; D005260:Female; D006279:Health Maintenance Organizations; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016015:Logistic Models; D008297:Male; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D008509:Medication Systems; D010372:Pediatrics / Q000592:standards*; D012189:Retrospective Studies; D012307:Risk Factors; D014481:United States