title: Therapeutic errors among children in the community setting: nature, causes and outcomes.
abstract: OBJECTIVE
  This study aimed to determine the epidemiology of therapeutic errors among children in the community setting.
  
  
  METHODS
  This was a prospective, observational study of 491 consecutive cases reported to the Victorian Poisons Information Centre, between January 2006 and March 2007. A total of 450 (91.7%) parents/carers were followed up by telephone approximately 48 h after the initial call. The main outcome measures were the nature, causes and outcomes of the errors and actions taken or recommendations given to avoid future errors.
  
  
  RESULTS
  The majority of children (334, 68.0%, 95% confidence interval (CI) 63.7, 72.1) were aged <or=3 years. Incorrect and double dosage accounted for 279 (56.8%, 95% CI 52.3, 61.2) and 128 (26.1%, 95% CI 22.3, 30.2) cases, respectively. Almost all errors occurred in the home (98.2%) and involved a single medication (98.8%) and the oral route (98.4%). Close family members were responsible in 408 (83.1%, 95% CI 79.4, 86.2) cases. Analgesics and cough and cold preparations were taken in error in 259 (52.0%) cases. Human (rushing, distraction, carelessness) and communication factors were reported to be causal factors in 337 (38.4%, 95% CI 35.2, 41.8) and 111 (12.7%, 95% CI 10.6, 15.1) cases, respectively. In almost all cases (474, 96.5%, 95% CI 94.4, 97.9), the caller was advised to observe the child at home, and no child experienced significant morbidity. Preventive strategies included attention to administration care and routine, communication, medication storage, administration devices, packaging and labelling issues.
  
  
  CONCLUSIONS
  Very young children are at particular risk, especially from single, over-the-counter medication dosing errors, made at home by family members.
authors.affiliation: Emergency andGeneral Medicine Research, Austin Health, Melbourne, Australia. david.taylor@austin.org.au
authors.forename: David
authors.initials: D
authors.lastname: McD Taylor
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Robinson
authors.forename: Dawson
authors.initials: D
authors.lastname: MacLeod
authors.forename: Catherine E
authors.initials: CE
authors.lastname: MacBean
authors.forename: George
authors.initials: G
authors.lastname: Braitberg