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


METHODS
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.


RESULTS
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.


CONCLUSIONS
The recurring circumstances underlying many of these errors suggest that preventing such errors may require systemic/process changes.
Tzimenatos
Leah
L
Cincinnati Children's Hospital Medical Center and Division of Emergency Medicine, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA. leah.tzimenatos@ucdmc.ucdavis.edu
Bond
G Randall
GR
D016907:Adverse Drug Reaction Reporting Systems / Q000706:statistics & numerical data*; D000367:Age Factors; D002675:Child, Preschool; D062787:Drug Overdose / Q000209:etiology / Q000401:mortality; D064420:Drug-Related Side Effects and Adverse Reactions; D006268:Health Facilities / Q000592:standards / Q000706:statistics & numerical data; D006701:Home Nursing / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D008508:Medication Errors / Q000401:mortality / Q000706:statistics & numerical data*; D004364:Pharmaceutical Preparations / Q000008:administration & dosage; D011039:Poison Control Centers / Q000706:statistics & numerical data*; D011041:Poisoning / Q000453:epidemiology* / Q000209:etiology / Q000401:mortality; D012189:Retrospective Studies; D012720:Severity of Illness Index; D014481:United States / Q000453:epidemiology
D004364:Pharmaceutical Preparations