Misdosing of Medications Prompts Most Poison Calls About Young Infants

Abstract

Source: Coco TJ, King WD, Slattery AP. Descriptive epidemiology of infant ingestion calls to a regional poison control center. South Med J. 2005;98:779–783.Children aged ≤6 months are poisoned primarily as a result of a caregiver providing the wrong dose of medication. Dosing based upon weight and body surface area and the need to measure small doses further increase risk. Researchers from the University of Alabama, Birmingham, retrospectively reviewed all calls to the Birmingham Regional Poison Control Center during a 1-year period (December 28, 2002–December 28, 2003). During that period, 358 calls concerned infants aged ≤6 months (mean age 4 months). Fifty-nine percent of ingestions involved medications, most commonly ranitidine (11%), metoclopramide (9%), acetaminophen (8%), and Dimetapp Infant Drops (6%). Fifty-three percent of the calls involved “therapeutic misadventures,” which were defined as any incorrect action occurring in the administration of a medication, including errors in prescribing, errors in dispensing the product to the consumer, dosing errors made by caregivers, and idiosyncratic reactions to medications. Nine percent of infants were given a medicine other than that recommended or prescribed, and in 3% of cases the pharmacy had dispensed the wrong medication to the caregiver.Dosing errors accounted for 41% of reported ingestions. In 29% of cases, the overdose was the result of incorrectly measured doses of the prescribed medication. Another 9% of infants received a dose of medication from a caregiver who was unaware that another caregiver had already administered the medication. Incorrect dosing interval or route accounted for 4% of cases. Ten-fold (decimal) dosing errors occurred in 8% of ingestions reported. Eighty percent of infants were treated at home and 11% in emergency departments. Symptoms of overdose were reported in 14% of infants.The authors conclude that since most calls to a poison control center regarding infant ingestions involve incorrect administration of a medication, medical providers and pharmacists need to discuss accurate dosing with caregivers of young infants and provide dosing syringes. These efforts should be augmented by development of less concentrated medications, which might mitigate the potential for overdosing.Dr. Nemeth has not disclosed any financial relationships relevant to this commentary. Dr. Katcher has not disclosed any financial relationships relevant to this commentary.Poisonings are among the most common types of injuries to children aged ≤6 months and require emergency room visits and hospitalizations.1,2 Errors in administration of medications to infants may be made by the medical provider, the pharmacist, or the caregiver. Efforts to prevent mistakes thus need to focus on all 3 sources. Physicians and other medical personnel who write prescriptions and provide dosing instructions may employ a number of interventions to reduce errors in either prescription filling by pharmacists or administration by caregivers: avoiding abbreviations,3,4 taking the time to write legibly,5 and using leading and trailing zeros appropriately.4 As electronic health record systems continue to be implemented, more of these provider errors may be reduced or eliminated. Writing (legibly) the doses for over-the-counter medications may also be helpful for parents as a back-up to what they were verbally told, as would the demonstration and dispensing of an oral dosing syringe.