Patient Safety and Quality

Frequent potential medication dosing errors occur during outpatient pediatric visits

Safe pediatric prescribing requires accurate weight, proper conversion of pounds to kilograms, and the choice of an appropriate preparation and concentration. A new study, supported in part by the Agency for Healthcare Research and Quality (HS10391, HS11843, and Contract No. 290-00-0015), found that about one in seven (15 percent) new prescriptions written for children during outpatient visits were potentially for the wrong dose. Eight percent were potential overdoses and 7 percent were potential underdoses. Among children weighing less than 35 kg, only 67 percent of medications were dispensed within recommended dosing ranges, which are based on weight for children. Pain-relievers (analgesics) were the class of medications most likely to be potentially overdosed (15 percent), whereas antiepileptics were the class of medications most likely to be potentially underdosed (20 percent).

One of every five children younger than 4 years of age receiving any medication, one in five children receiving a "prn" (as-needed) medication, and one in six children receiving an analgesic received a potentially improperly dosed medication. Young and medically complex children, who are most vulnerable to potentially serious adverse drug events, were most likely to be dispensed potential drug overdoses.

These findings were based on analysis of pharmacy data from three health maintenance organizations (HMOs) on 1,933 children with a newly dispensed prescription for drugs in six categories: analgesics, antibiotics, antiepileptics, asthma and allergy medications, and isotretrinoin. Potential error rates were no lower at the HMO that used an electronic prescription writer than at the two HMOs that used paper prescriptions. However, many electronic prescribing systems do not contain weight-based dosage decision support or alert mechanisms for potential underdosing or overdosing of medication based on weight.

See "Potential medication dosing errors in outpatient pediatrics," by Heather A. McPhillips, M.D., M.P.H., Christopher J. Stille, M.D., M.P.H., David Smith, R.Ph., M.H.A., Ph.D., and others, in the December 2005 Journal of Pediatrics 147, pp. 761-767.

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