Severe injury or death in young children from therapeutic errors: a summary of 238 cases from the American Association of Poison Control Centers

Clin Toxicol (Phila). 2009 Apr;47(4):348-54. doi: 10.1080/15563650902897650.


Introduction: Medication-related errors pose a risk to children, but accurate data regarding errors with clinically significant outcomes are not available. We attempt to describe errors, identify patterns of error, and find targets for prevention using a large series of pediatric therapeutic errors with severe outcomes.

Methods: A national, retrospective poison center chart review study including all cases of severe injury or death from therapeutic error involving children less than 6 years which were reported to the American Association of Poison Control Centers from 2000-2004 was performed.

Results: Among 272 cases identified, 238 were included in analysis and 34 were excluded; 162 cases occurred in the home and 70 in health care facilities. Significant errors disproportionately affected children less than 1 year (107/238 cases, 45%). The majority of errors were due to excessive dosing (171/238, 72%). Common mechanisms of error were identified: 10-fold errors, confusion about formulation or units of measure, increased frequency, and adult dosing.

Conclusions: The recurring circumstances underlying many of these errors suggest that preventing such errors may require systemic/process changes.

MeSH terms

  • Adverse Drug Reaction Reporting Systems / statistics & numerical data*
  • Age Factors
  • Child, Preschool
  • Drug Overdose / etiology
  • Drug Overdose / mortality
  • Drug-Related Side Effects and Adverse Reactions*
  • Health Facilities / standards
  • Health Facilities / statistics & numerical data
  • Home Nursing / standards
  • Home Nursing / statistics & numerical data
  • Humans
  • Infant
  • Medication Errors / mortality
  • Medication Errors / statistics & numerical data*
  • Pharmaceutical Preparations / administration & dosage
  • Poison Control Centers / statistics & numerical data*
  • Poisoning / epidemiology*
  • Poisoning / etiology
  • Poisoning / mortality
  • Retrospective Studies
  • Severity of Illness Index
  • United States / epidemiology


  • Pharmaceutical Preparations