Studies Highlight Common Child Medication Errors

Two recent studies published in the July 14 on-line version of the journal Pediatrics highlight common child medication errors and present some solutions. The studies focused on two distinct areas: practices that reduce error in doctors’ offices and hospitals; and the reasons for medication errors that take place at home with parents.

The studies consider a significant problem. Because children are more sensitive than adults, even minor errors can result in serious poisoning problems with overdoses, or inadequate treatment with doses that are too small. According to one study, 10,000 calls to poison control centers every year occur in relation to incorrect dosage issues, and as many as 7,000 children die due to such errors.

Doctors and prescription errors

The first article was a review of 63 different studies conducted by researchers at Children’s Hospital at Montefiore in Bronx, New York. These studies, published in a variety of journals, surveyed strategies employed to reduce prescription errors and their effectiveness.

The survey’s lead author, Dr. Michael L. Rinke, noted that doctor-related medication errors were far easier to track and analyze than those that took place at home; moreover, variations in results could be observed from one study to another. However, certain interventions emerged in the studies as particularly efficacious.

Many of these interventions involved the computerization and systemization of prescription practices. For instance, the use of preprinted order sheets, which eliminated problems with handwriting illegibility, and the use of computerized provider order entry (any system in which a medical provider enters a prescription directly into the computer) both significantly reduced errors on the doctor’s end. Any prescription inputting system in which the computer included prescribing guidelines and reminders also reduced errors.

Also significant were clear instructions given by doctors, working closely with nurses and pharmacists, to make sure that parents understand how to administer medications to their children.

Parents and child medication errors

The second study considered the reasons that parents measured incorrect doses of medication for their children at home. The study was conducted by researchers at New York University School of Medicine and followed 287 parents of children prescribed liquid medication while in the emergency room. Dr. Shonna Yin, lead author, and her colleagues observed the parents measuring medication and found that just over 40% made mistakes.

Errors occurred when parents did not understand dosing directions, or when they did not have a clear sense of how much they were actually dispensing. A prime culprit was prescriptions that called for medication doses given in teaspoons or tablespoon measurements. Because kitchen spoons can vary in sizes, doses will also vary, resulting in child medication errors that can have dangerous consequences.

Researchers found that when prescriptions were given in this fashion, parents were 2.3 times more likely to pour the wrong dose overall than if the prescriptions were given in metric measurements.

Researchers recommend that prescriptions for liquid medication now be given in milliliters, which can be administered with an oral syringe. Because the plastic syringes have accurate measurements written on the sizes, parents are less likely to measure their children’s medications inaccurately.