Potential medication dosing errors in outpatient pediatrics

Potential medication dosing errors in outpatient pediatrics.
McPhillips H.A. , Stille C.J. , Smith D. , Hecht J. , Pearson J. , Stull J. , Debellis K.P. , Andrade S. , Miller M. , Kaushal R. , Gurwitz J. & Davis R.L.(2005)Journal of Pediatrics,147,761–767.Objective  To determine the prevalence of potential dosing errors of medication dispensed to children for 22 common medications. Study design  The investigators used automated pharmacy data from three health maintenance organizations. Children were eligible if they were less than 17 years old at the time of dispensing. The investigators 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 under‐doses. The error rate in two health maintenance organizations that use paper prescriptions was compared with one health maintenance organization 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 under‐doses. Among children weighing less than 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 anti‐epileptics were most likely potentially under‐dosed (20%). Potential error rates were not lower at the site with an electronic prescription writer. Conclusions  Potential medication dosing errors occur frequently in outpatient paediatrics. Studies on the clinical impact of these potential errors and effective error prevention strategies are needed.