Potential medication dosing errors in outpatient pediatrics.
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.
McPhillips
Heather A
HA
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
Stille
Christopher J
CJ
Smith
David
D
Hecht
Julia
J
Pearson
John
J
Stull
John
J
Debellis
Kristin
K
Andrade
Susan
S
Miller
Marlene
M
Kaushal
Rainu
R
Gurwitz
Jerry
J
Davis
Robert L
RL
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