Medication Dosing Errors Research Articles

Towards more reliable automated multi-dose dispensing: retrospective follow-up study on medication dose errors and product defects

To date, little is known on applicability of different types of pharmaceutical dosage forms in an automated high-speed multi-dose dispensing process. The purpose of the present study was to identify and further investigate various process-induced and/or product-related limitations associated with multi-dose dispensing process. The rates of product defects and dose dispensing errors in automated multi-dose dispensing were retrospectively investigated during a 6-months follow-up period. The study was based on the analysis of process data of totally nine automated high-speed multi-dose dispensing systems. Special attention was paid to the dependence of multi-dose dispensing errors/product defects and pharmaceutical tablet properties (such as shape, dimensions, weight, scored lines, coatings, etc.) to profile the most suitable forms of tablets for automated dose dispensing systems. The relationship between the risk of errors in dose dispensing and tablet characteristics were visualized by creating a principal component analysis (PCA) model for the outcome of dispensed tablets. The two most common process-induced failures identified in the multi-dose dispensing are predisposal of tablet defects and unexpected product transitions in the medication cassette (dose dispensing error). The tablet defects are product-dependent failures, while the tablet transitions are dependent on automated multi-dose dispensing systems used. The occurrence of tablet defects is approximately twice as common as tablet transitions. Optimal tablet preparation for the high-speed multi-dose dispensing would be a round-shaped, relatively small/middle-sized, film-coated tablet without any scored line. Commercial tablet products can be profiled and classified based on their suitability to a high-speed multi-dose dispensing process.

Medication Dosing Errors in Pediatric Patients Treated by Emergency Medical Services

Bakground. Medication dosing errors occur in up to 17.8% of hospitalized children. There are limited data to describe pediatric medication errors by emergency medical services (EMS) paramedics. It has been shown that paramedics have infrequent encounters with pediatric patients. Objective. To characterize medication dosing errors in children treated by EMS. Methods. We studied patients aged ≤11 years who were treated by paramedics from eight Michigan EMS agencies from January 2004 through March 2006. We defined a medication dosing error as ≥20% deviation from the weight-appropriate dose, as determined by the patient's reported weight in the prehospital medical record or by use of the Broselow-Luten tape (BLT). We studied errors in administering six EMS medications commonly given to children: albuterol, atropine, dextrose, diphenhydramine, epinephrine, and naloxone. Results. There were 5,547 children aged ≤11 years who were treated during the study period, of whom 230 (4.1%) received drugs and had a documented weight. These patients received a total of 360 medication administrations. Multiple drug administrations occurred in 73 cases. Medication dosing errors occurred in 125 of the 360 drug administrations (34.7%; 95% confidence interval [CI] 30.0, 39.8). Relative drug dosage errors (with 95% CI) were as follows: albuterol 23.3% (18.4, 29.1), atropine 48.8% (34.3, 63.5), diphenhydramine 53.8% (29.1, 76.8), and epinephrine 60.9% (49.9, 73.9). The mean error (± standard deviation) for intravenous/intraosseous 1:1000 epinephrine overdoses was 808% ± 428%. The mean error (± standard deviation) for intravenous/intraosseous 1:1000 epinephrine underdoses was 35.5% ± 27.4%. Conclusions. Medications delivered in the prehospital care of children were frequently administered outside of the proper dose range when compared with patient weights recorded in the prehospital medical record. EMS systems should develop strategies to reduce pediatric medication dosing errors. Key words: pediatric; medical errors; medications; emergency medical services; patient safety.

Transient Impact of Automated Glomerular Filtration Rate Reporting on Drug Dosing for Hospitalized Older Adults With Concealed Renal Insufficiency

Background Older adults with concealed renal insufficiency are at risk of medication dosing errors. It is not known whether automated estimated glomerular filtration rate (eGFR) reporting is associated with reduced dosing errors in this population. Objective The goal of the present study was to examine the impact on prescribing patterns in older adults with concealed renal insufficiency for a variety of renally cleared medications before and after the addition of automated eGFR reporting. Methods We performed a retrospective chart review at a single tertiary academic medical center among hospitalized patients aged ≥70 years with concealed renal insufficiency. Data were examined from the months of July, December, and May before and after the hospital initiated automated eGFR reporting, in 2006–2007 and 2008–2009, respectively. Doses of selected renally cleared medications were classified as appropriate or inappropriate on the basis of published recommendations. Regression models were used to identify demographic, clinical, and care factors associated with dosing appropriateness. Results Before implementation of automated eGFR reporting, we observed 260 persons in whom 42.2% of relevant prescriptions were inappropriately dosed; after implementation, there were 280 subjects in whom 36.6% of relevant prescriptions were inappropriately dosed. The multivariable model suggested an overall trend toward less inappropriate dosing after automated eGFR reporting began, compared with rates before (adjusted odds ratio [AOR] = 0.75 [95% confidence interval: 0.52–1.07], P = 0.11). However, a gradient was observed as the academic year progressed. A marked reduction in the rate of inappropriate medication dosing was seen in July after initiation of eGFR reporting compared with the July before initiation (AOR = 0.28; P < 0.01). This effect was attenuated in December (AOR = 0.45; P = 0.05) and gone by May (AOR = 0.85; P = 0.67). Conclusion Automated eGFR reporting alone, without any order entry intervention, was associated only transiently with improved dosing appropriateness for these older adults with concealed renal insufficiency.

Response to Medication Dosing Alerts for Pediatric Inpatients Using a Computerized Provider Order Entry System

Medication dosing errors are of particular concern in hospitalized children. Avoidance of such errors is essential to quality improvement and patient safety. Computerized provider order entry (CPOE) systems with clinical decision support (CDS) have the potential to reduce medication errors. The objective of this study was to evaluate provider response to the dosing alerts in a CPOE system with CDS for pediatric inpatients and to identify differences in provider response based on clinician specialty. We conducted a retrospective analysis of all medication dosing alerts over a 1-year period (January 1 through December 31, 2008) for all pediatric inpatients at Hospital for Special Surgery. Alerts were analyzed with respect to medication dosing, prescriber, and action taken by the prescriber after the alert was triggered (i.e., accepted suggested change, ignored recommendation/overrode, or cancelled the order). During the study period, 18,163 medication orders were placed and 1,024 dosing alerts were fired. Overdosing of medications accounted for 91% of the alerts and underdosing 9%. The pediatric-trained providers ignored more alerts and cancelled fewer orders than the non-pediatric-trained providers (p<0.001). Both groups changed the order similarly based on CDS recommendations. Differences in response to CDS were found between pediatric-trained and non-pediatric-trained providers caring for pediatric patients; however, both groups changed orders based on CDS similarly. CPOE with built-in CDS may be of particular value when providers with different specialties and types of training are caring for pediatric patients.

Use of a Pictographic Diagram to Decrease Parent Dosing Errors With Infant Acetaminophen: A Health Literacy Perspective

Objective Medication dosing errors by parents are frequent. We sought to whether a pictographic dosing diagram could improve parent ability to dose infant acetaminophen, and to determine whether pictogram benefit varies by health literacy level. Methods We conducted an experimental study of parents presenting with their children to an urban public hospital pediatric clinic. Caregivers were randomized to dose infant acetaminophen with a standard dropper using text-only or text-plus-pictogram instructions (pictographic diagram of dose). The primary outcome variable was dosing accuracy (error defined as >20% deviation above/below dose; large overdosing error defined as >1.5 times recommended dose). Caregiver health literacy was assessed by means of the Newest Vital Sign measure. Results A total of 299 parents were assessed (144 text-only instructions; 155 text plus pictogram); 77.9% had limited health literacy (Newest Vital Sign score 0–3). Text-plus-pictogram recipients were less likely to make an error compared to text-only recipients (43.9% vs 59.0%, P = .01; absolute risk reduction, 15.2% [95% confidence interval, 3.8–26.0]; number needed to treat, 7 [4–26]). Of text-plus-pictogram recipients, 0.6% made a large overdosing error compared to 5.6% of text-only recipients (absolute risk reduction, 4.9% [0.9–10.0]; number needed to treat, 20 [10–108]). Pictogram benefit varied by health literacy, with a statistically significant difference in dosing error evident in the text-plus-pictogram group compared to the text-only group among parents with low health literacy (50.4% vs 66.4%; P = .02), but not for parents with adequate health literacy ( P = .7). Conclusions Inclusion of pictographic dosing diagrams as part of written medication instructions for infant acetaminophen may help parents provide doses of medication more accurately, especially those with low health literacy. High error rates, even among parents with adequate health literacy, suggest that additional study of strategies to optimize dosing is needed.

Development of a Point-of-Care HIV/Aids Medication Dosing Support System Using the Android Mobile Platform

Medication dosing errors can greatly reduce HIV treatment effectiveness as incorrect dosing leads to drug resistance and non-adherence. In order to dose correctly, HIV therapy providers must balance several patient characteristics such as renal functions and weight. In developing countries and other resource-limited settings, dosing errors are more likely because treatment is provided by mid-level providers with only basic training in HIV therapy. These providers also typically lack electronic tools informing medical decisions. Widespread adoption of mobile phones in developing nations offers an opportunity to implement a point-of-care system to help providers reduce dosing errors. We discuss the development of the mHIV-Dr system prototype using the new Android mobile platform. mHIV-Dr is being designed to provide dosing recommendations for front-line providers in developing countries. We also discuss the additional challenges in the implementation of the mHIV-Dr system in a resource limited setting.

Severe thrombosis and acute thrombocytopenia in a cancer patient

A 62-year-old Caucasian female who had recently been diagnosed with multiple myeloma with a sacral plasmacytoma received induction treatment with bortezomib, cyclophosphamide, and dexamethasone. She had a significant response to therapy and had just begun the process of mobilization and collection of peripheral blood progenitor cells for autologous stem cell transplantation when she presented to the emergency center (EC) with pain and swelling of the left upper extremity. Her blood pressure on presentation was 114/69 mmHg with a heart rate of 98 beats per minute. Serum sodium was 136 mEq/L, potassium 4.3 mEq/L, chloride 98 mEq/L, carbon dioxide 24 mEq/L, blood urea nitrogen 9 mg/dL, serum creatinine 0.6 mg/dL, glucose 119 mg/dL, calcium 8.6 mg/dL, albumin 3.9 mg/dL, phosphorus 2.5 mg/dL, and magnesium 2.1 mg/dL. Liver function tests were within normal limits, with the exception of lactate dehydrogenase that was elevated at 728 IU/L. Prothrombin time (PT) was 16.5 sec (normal 12.7―15 sec), international normalized ratio (INR) 1.24, and activated PTT (aPTT) was 38.3 sec (normal 24.7―35.9 sec). D-dimer was >20 μg/mL (normal 0―0.4 μg/dL) and fibrinogen was 424 mg/dL. A complete blood count (CBC) showed a white blood cell (WBC) count of 11,400/μL, hemoglobin of 11.6 g/dL, and platelet count of 14,000/μL. Review of the peripheral smear revealed the presence of anisocytosis and ovalocytes, and the absence of fragmented red blood cells (schistocytes). The platelet count had dropped from 316,000/μL to 14,000/μL in a 7-day period (see Fig. 1). Home medications included zolpidem, lorazepam, duloxetine, famotidine, fentanyl, hydromorphone, and ondansetron. Doppler ultrasound study showed a completely occlusive thrombus within the left internal jugular vein extending to the subclavian, axillary, brachial, and basilic veins. The patient had recently had a left subclavian central venous catheter (CVC) placed 11 days prior to presenting to the EC. The CVC was removed, but no anticoagulation was started secondary to severe thrombocytopenia.

Physician Order Entry Or Nurse Order Entry? Comparison of Two Implementation Strategies for a Computerized Order Entry System Aimed at Reducing Dosing Medication Errors

Background Despite the significant effect of computerized physician order entry (CPOE) in reducing nonintercepted medication errors among neonatal inpatients, only a minority of hospitals have successfully implemented such systems. Physicians' resistance and users' frustration seem to be two of the most important barriers. One solution might be to involve nurses in the order entry process to reduce physicians’ data entry workload and resistance. However, the effect of this collaborative order entry method in reducing medication errors should be compared with a strictly physician order entry method.Objective To investigate whether a collaborative order entry method consisting of nurse order entry (NOE) followed by physician verification and countersignature is as effective as a strictly physician order entry (POE) method in reducing nonintercepted dose and frequency medication errors in the neonatal ward of an Iranian teaching hospital.Methods A four-month prospective study was designed with two equal periods. During the first period POE was used and during the second period NOE was used. In both methods, a warning appeared when the dose or frequency of the prescribed medication was incorrect that suggested the appropriate dosage to the physicians. Physicians’ responses to the warnings were recorded in a database and subsequently analyzed. Relevant paper-based and electronic medical records were reviewed to increase credibility.Results Medication prescribing for 158 neonates was studied. The rate of nonintercepted medication errors during the NOE period was 40% lower than during the POE period (rate ratio 0.60; 95% confidence interval [CI] .50, .71;P < .001). During the POE period, 80% of nonintercepted errors occurred at the prescription stage, while during the NOE period, 60% of nonintercepted errors occurred in that stage. Prescription errors decreased from 10.3% during the POE period to 4.6% during the NOE period (P < .001), and the number of warnings with which physicians complied increased from 44% to 68% respectively (P < .001). Meanwhile, transcription errors showed a nonsignificant increase from the POE period to the NOE period. The median error per patient was reduced from 2 during the POE period to 0 during the NOE period (P = .005). Underdose and curtailed and prolonged interval errors were significantly reduced from the POE period to the NOE period. The rate of nonintercepted overdose errors remained constant between the two periods. However, the severity of overdose errors was lower in the NOE period (P = .02).ConclusionsNOE can increase physicians' compliance with warnings and recommended dose and frequency and reduce nonintercepted medication dosing errors in the neonatal ward as effectively as POE or even better. In settings where there is major physician resistance to implementation of CPOE, and nurses are willing to participate in the order entry and are capable of doing so, NOE may be considered a beneficial alternative order entry method.

Liquid medication dosing errors: a pre-post time series in India

AbstractObjectiveTo evaluate the influence of pharmacist intervention on the level of parental dosing measurement errors and paediatrician dosage prescribing in a clinic in India.Setting and study designThe study was conducted at Srujan Hospital for Sick Children, India. It used a time series design with two groups of patients. Group 1 involved 175 children prescribed paracetamol and assigned to usual care. Following an educational intervention for the hospital paediatricians, including feedback on dosages prescribed for Group 1 and promotion of a dosing chart, 162 patients were recruited to the intervention group (Group 2). Parents in Group 1 received paracetamol suspension and verbal instructions from hospital staff (standard care). Parents in Group 2 were provided with a syringe with a line marking the prescribed dose and its use was demonstrated to them by the pharmacist. Data on the dosages prescribed and measurement accuracy by parents were obtained for both groups.Main outcome measuresMeasurement of correct dosages by parents, and prescribing of appropriate dosages by paediatricians.ResultsIn Group 1, 85 of 175 parents (48.6%) measured the correct dose (±0.5 ml) and paediatricians prescribed appropriate dosages in 67 of 175 cases (38.2%). In Group 2, 160 of 162 parents (98.7%) measured the correct dose and paediatricians prescribed appropriate dosages in 160 of 162 cases (98.7%), showing statistically significant improvements in both indicators (P &amp;lt; 0.001). When the impact of prescribing and dosing correctness was combined on an individual patient basis, 76 of 175 (43.4%) were appropriate in Group 1, and 160 of 162 (98.7%) were appropriate in Group 2. There was a statistically significant improvement (P &amp;lt; 0.001) in appropriate dosing outcome between the two groups.ConclusionPharmacist intervention through patient education, including the use of a syringe, significantly improved parents' dosing accuracy. Pharmacists' feedback resulted in a reduction in physicians' prescribing errors in a country where pharmacist involvement is currently minimal.

Drug Use and Dosing in Chronic Kidney Disease

One of the most important drug-related problems in patients with chronic kidney disease (CKD) is medication dosing errors. Many medications and their metabolites are eliminated through the kidney. Thus, adequate renal function is important to avoid toxicity. Patients with renal impairment often have alterations in their pharmacokinetic and pharmacodynamic parameters. The clearance of drugs eliminated primarily by renal filtration is decreased by renal disease. Therefore, special consideration should be taken when these drugs are prescribed to patients with impaired renal function. Despite the importance of dosage adjustment in patients with CKD, such adjustments are sometimes ignored. Physicians and pharmacists can work together to accomplish safe drug prescribing. This task can be complex and require a stepwise approach to ensure effectiveness, minimise further damage and prevent drug nephrotoxicity.

The Effect of Computerized Physician Order Entry and Decision Support System on Medication Errors in the Neonatal Ward: Experiences from an Iranian Teaching Hospital

Medication dosing errors are frequent in neonatal wards. In an Iranian neonatal ward, a 7.5 months study was designed in three periods to compare the effect of Computerized Physician Order Entry (CPOE) without and with decision support functionalities in reducing non-intercepted medication dosing errors in antibiotics and anticonvulsants. Before intervention (Period 1), error rate was 53%, which did not significantly change after the implementation of CPOE without decision support (Period 2). However, errors were significantly reduced to 34% after that the decision support was added to the CPOE (Period 3; P < 0.001). Dose errors were more often intercepted than frequency errors. Over-dose was the most frequent type of medication errors and curtailed-interval was the least. Transcription errors did not reduce after the CPOE implementation. Physicians ignored alerts when they could not understand why they appeared. A suggestion is to add explanations about these reasons to increase physicians' compliance with the system's recommendations.

Therapeutic errors among children in the community setting: nature, causes and outcomes

This study aimed to determine the epidemiology of therapeutic errors among children in the community setting. 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. 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. Very young children are at particular risk, especially from single, over-the-counter medication dosing errors, made at home by family members.

Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports

Objectives:To examine the characteristics of incidents reported after introduction of a voluntary, non-punitive incident reporting system for neonatal intensive care units (NICUs) in the Netherlands; and to investigate which types...

Randomized Controlled Trial of a Pictogram-Based Intervention to Reduce Liquid Medication Dosing Errors and Improve Adherence Among Caregivers of Young Children

To evaluate the efficacy of a pictogram-based health literacy intervention to decrease liquid medication administration errors by caregivers of young children. Randomized controlled trial. Urban public hospital pediatric emergency department. Parents and caregivers (N = 245) of children aged 30 days to 8 years who were prescribed liquid medications (daily dose or "as needed"). Medication counseling using plain language, pictogram-based medication instruction sheets. Control subjects received standard medication counseling. Medication knowledge and practice, dosing accuracy, and adherence. Of 245 randomized caregivers, 227 underwent follow-up assessments (intervention group, 113; control group, 114). Of these, 99 were prescribed a daily dose medication, and 158 were prescribed medication taken as needed. Intervention caregivers had fewer errors in observed dosing accuracy (>20% deviation from prescribed dose) compared with caregivers who received routine counseling (daily dose: 5.4% vs 47.8%; absolute risk reduction [ARR], 42.4% [95% confidence interval, 24.0%-57.0%]; number needed to treat [NNT], 2 [2-4]; as needed: 15.6% vs 40.0%; ARR, 24.4% (8.7%-38.8%); NNT, 4 [3-12]). Of intervention caregivers, 9.3% were nonadherent (ie, did not give within 20% of the total prescribed doses) compared with 38.0% of controls (ARR, 28.7% [11.4%-43.7%]; NNT, 3 [2-9]). Improvements were also seen for knowledge of appropriate preparation for both medication types, as well as knowledge of frequency for those prescribed daily dose medications. A plain language, pictogram-based intervention used as part of medication counseling resulted in decreased medication dosing errors and improved adherence among multiethnic, low socioeconomic status caregivers whose children were treated at an urban pediatric emergency department. clinicaltrials.gov Identifier: NCT00537433.

Medication dosing errors in hospitalized patients with renal impairment: a study in Palestine

Reduced renal function requires dose adjustment for certain drugs to avoid toxicity. The aim of this study was to determine whether appropriate dosage adjustments were made for drugs that are nephrotoxic, excreted, or metabolized (TEM medications) by the kidney in patients with renal impairment. A cross-sectional study of a group of hospitalized patients was carried out at Al-Watni governmental hospital, Nablus, Palestine. All patients with creatinine clearance </=59 ml/min were included in the analysis. Data regarding patients' clinical, laboratory findings and medications whether they were prescribed at hospital or at discharge were collected from patients' medical files. Evaluation of appropriate dosing was based on Physician Disk Reference (PDR). All data were collected for further research and subsequent statistical analysis using statistical package for social sciences (SPSS) for windows version 10. A total of 78 patients had calculated creatinine clearance </=59 ml/min. Those patients were prescribed a total of 1001 lines of prescription medication. Dosage adjustment was necessary for 193 TEM medications. Analysis of TEM medications with guidelines for adjustment indicated that 73.58%(142) were found to be inappropriate and 26.42% (51) were found to be appropriate. The most common inappropriate medications were ranitidine, antibiotics, and digoxin. Approximately 77.5% of the unadjusted medications were prescribed during hospitalization. In our study, a wide range of dosing errors was common among patients with renal impairment that was common during hospitalization. Continued medical education in the field of clinical pharmacokinetics is important for physicians.

Reporting of estimated glomerular filtration rate: Effect on physician recognition of chronic kidney disease and prescribing practices for elderly hospitalized patients

Physician recognition of chronic kidney disease (CKD) in elderly patients has been noted to be poor. These patients are at increased risk of medication dosing errors and acute renal failure. To investigate the effect of reporting estimated glomerular filtration rate (GFR) of elderly hospitalized patients on physician recognition of CKD and physician prescribing behaviors. A retrospective combined with a prospective medical record review project. A large academic medical center. Patients included were 65 years of age or older and had creatinine values within the normal laboratory range (< 1.6 mg/dL). Reporting a calculated estimate of GFR to physicians. Rates of recognition of CKD were examined before and after the intervention. The effects of the intervention on prescription of renal-dosed antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDS) and cyclooxygenase- 2 inhibitors (COX-2) at hospital discharge were assessed. A total of 260 and 198 patients were included before and after the intervention, respectively. Recognition of chronic kidney disease was low in both groups but demonstrated a significant increase following reporting of estimated GFR (3.9% to 12.6%, P < .001). Reporting of GFR was not associated with a significant decrease in prescription of NSAID/COX-2 medications or increased rates of correct dosing of antibiotics (P = .10 and P = .81, respectively). Although reporting of estimated GFR was associated with improved physician recognition of CKD in elderly hospitalized patients, it did not lead to a change in physician prescribing. More extensive interventions are necessary to increase recognition and decrease medication dosing errors.

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. &amp; Davis R.L. ( 2005 ) , 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.

Evaluation of a Web-Based Education Program on Reducing Medication Dosing Error

The Broselow Pediatric Resuscitation Tape has been shown to be effective in reducing medication dosing error among pediatric emergency providers. However, the tape has often been used inappropriately or incorrectly. To evaluate whether a Web-based education program on proper use of the tape could reduce medication dosing errors and time to determine dose. A randomized, controlled trial conducted among 89 pediatric emergency providers from 3 study sites. All study subjects participated in a videotaped simulated stabilization scenario and were then randomly assigned to control or education group. After the intervention, all subjects participated in another simulation. The primary outcomes included dosing deviation from accepted dose range for each medication prescribed and dosing deviation summary, calculated by averaging dosing deviation for all medications. The secondary outcomes included time to determine a dose for each medication prescribed, and dosing time summary; that is, the average time to determine doses for all medications prescribed. No significant difference was observed in the demographic characteristics of the 2 groups. After the educational intervention, the average (12.6% vs. 24.9%) and median (7.1% vs. 20.1%) dosing deviation summary were much lower in the education group than in the control group. The difference in the median dosing deviation summary between the 2 groups was statistically significant (P = 0.0002). Similar results were observed for the dosing time. The education group demonstrated a lower average (16 vs. 20 seconds) and lower median (15 vs. 18 seconds) dosing time summary than the control group. The difference in the median dosing time summary between the 2 groups was statistically significant (P = 0.02). Analysis of each medication prescribed indicated that the decrease in the dosing deviation and dosing time in the education group was most obvious for several specific medications. The Web-based education program on the proper use of the Broselow Pediatric Resuscitation Tape could improve dosing accuracy and reduce dosing time.

Potential Medication Dosing Errors in Outpatient Pediatrics

To determine the prevalence of potential dosing errors of medication dispensed to children for 22 common medications. Using automated pharmacy data from 3 health maintenance organizations (HMOs), we 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 underdoses. Error rate in 2 HMOs that use paper prescriptions was compared with 1 HMO that uses an electronic prescription writer. Approximately 15% of children were dispensed a medication with a potential dosing error: 8% were potential overdoses and 7% were potential underdoses. Among children weighing <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 antiepileptics were most likely potentially underdosed (20%). Potential error rates were not lower at the site with an electronic prescription writer. Potential medication dosing errors occur frequently in outpatient pediatrics. Studies on the clinical impact of these potential errors and effective error prevention strategies are needed.

Medication Dosing Errors for Patients with Renal Insufficiency in Ambulatory Care

Approximately 8.7 million (3%) Americans have various degrees of chronic renal insufficiency (CRI). Patients with CRI are susceptible to adverse drug events related to improper dose adjustment of drugs that are eliminated primarily unchanged through the kidney. Renal dosing errors are an important quality-of-care problem in the inpatient setting, yet little is known about dosing errors for patients with renal insufficiency in the outpatient setting. Electronic records were queried to identify patients with CRI (estimated creatinine clearance < 50 mL/min) who visited the ambulatory care clinic at least once from January 1, 2003 through December 31, 2003. Of the total of 224 patients identified with CRI, 157 (70%) received one or more of 17 drugs with high rates of renal elimination. A total of 207 drugs requiring dose adjustment were prescribed to these patients, and 52 (25%) were prescribed at an inappropriately high dose. For 127 (57%) of the 224 patients, CRI was not documented. Patients with documented CRI were equally likely to be prescribed an inappropriately high dose of a target drug. Incorrect dosing of medications among patients with CRI is common in the ambulatory care setting. Strategies for preventing medication dosing errors can target the prescribing and monitoring stages of pharmaceutical care.