Tenfold therapeutic dosing errors in young children reported to U.S. poison control centers

American Journal of Health-System Pharmacy

Volumn 66, Issue 14, 2009, Pages 1292-1296

  Crouch, Barbara Insley ^a,b   Caravati, E Martin ^c   Moltz, Ed ^b  

^a Utah Poison Control Center   (United States)

^b UNIVERSITY OF UTAH   (United States)

^c Division of Emergency Medicine (CBF)   (Germany)

Author keywords

Data collection; Dosage; Errors, medication; Gastrointestinal drugs; Metoclopramide; Pediatrics; Poison control centers; Poisoning

Indexed keywords

ANTIBIOTIC AGENT; ANTITUSSIVE AGENT; BENZODIAZEPINE DERIVATIVE; CALCIUM CHANNEL BLOCKING AGENT; CLONIDINE; DECONGESTIVE AGENT; HISTAMINE H2 RECEPTOR ANTAGONIST; LAXATIVE; METOCLOPRAMIDE; MORPHINE; PARACETAMOL; PHENYTOIN; RANITIDINE;

ARTICLE; CHILD; CHILD CARE; CONTROLLED STUDY; DRUG EXPOSURE; DRUG INTOXICATION; HEALTH CARE FACILITIES AND SERVICES; HUMAN; MAJOR CLINICAL STUDY; MEDICATION ERROR; OUTCOME ASSESSMENT; PRESCHOOL CHILD; PRIORITY JOURNAL; UNITED STATES;

EID: 67650941900     PISSN: 10792082     EISSN: None     Source Type: Journal    
DOI: 10.2146/080377     Document Type: Article

References (16)

1. Kohn LT, Corrigan JM, Donaldson MD, eds. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.
2. Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
3. Aspden P, Wolcott JA, Bootman JL et al., eds. Preventing medication errors: Quality Chasm Series. Washington, DC: National Academies Press; 2006:109.
4. Bronstein AC, Spyker DA, Cantilena LR et al. 2006 annual report of the American Association of Poison Control Centers' National Poison Data System (NPDS). Clin Toxicol. 2007; 45:815-917.
5. Litovitz TL, Klein-Schwartz W, White S et al. 2000 annual report of the American Association of Poison Control Centers' Toxic Exposure Surveillance System. Am J Emerg Med. 2001; 19:337-395
6. 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
7. Lesar TS. Tenfold medication dose prescribing errors. Ann Pharmacother. 2002; 36:1833-1839
8. American Academy of Pediatrics Committee on Pediatric Emergency Medicine. Patient safety in the pediatric emergency care setting. Pediatrics. 2007; 120:1367-1375
9. Lesar TS. Errors in the use of medication dosage equations. Arch Pediatr Adolesc Med. 1998; 152:340-344
10. Koren G, Barzilay Z, Modan M. Errors in computing drug doses. Can Med Assoc J. 1983; 129:721-723
11. Rowe C, Koren T, Koren G. Errors by paediatric residents in calculating drug doses. Arch Dis Child. 1998; 79:56-58 (Pubitemid 28331255)
12. Leonard MS, Cimino M, Shaha S et al. Risk reduction for adverse drug events through sequential implementation of patient safety initiatives in a children's hospital. Pediatrics. 2006; 118:e1124-9. (Pubitemid 46393761)
13. Kozer E, Scolnik D, Macpherson A et al. The effect of a short tutorial on the incidence of prescribing errors in pediatric emergency care. Can J Clin Pharmacol. 2006; 13:e285-91. (Pubitemid 44706206)
14. Institute for Safe Medication Practices. 1SMP medication safety alert! FDA advise-ERR: medication errors associated with levothyroxine products. www.ismp.org/newsletters/acutecare/articles/20000906-2.asp (accessed 2008 Jun 27).
15. McMahon SR, Rimsza ME, Bay RC. Parents can dose liquid medication accurately. Pediatrics. 1997; 100:330-333 (Pubitemid 127471128)
16. Litovitz T. The TESS database. Use in product safety assessment. Drug Saf. 1998; 18:9-19.