Potential medication dosing errors in outpatient pediatrics

J Pediatr. 2005 Dec;147(6):761-7. doi: 10.1016/j.jpeds.2005.07.043.


Objective: To determine the prevalence of potential dosing errors of medication dispensed to children for 22 common medications.

Study design: 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.

Results: 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.

Conclusions: 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.

Publication types

  • Multicenter Study
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Ambulatory Care / standards*
  • Child
  • Child, Preschool
  • Drug Prescriptions*
  • Female
  • Health Maintenance Organizations
  • Humans
  • Infant
  • Infant, Newborn
  • Logistic Models
  • Male
  • Medication Errors / prevention & control
  • Medication Errors / statistics & numerical data*
  • Medication Systems
  • Pediatrics / standards*
  • Retrospective Studies
  • Risk Factors
  • United States