Pediatric antidepressant medication errors in a national error reporting database

Abstract

Objective: To describe inpatient and outpatient pediatric antidepressant medication errors.

Methods: We analyzed all error reports from the United States Pharmacopeia MEDMARX database, from 2003 to 2006, involving antidepressant medications and patients younger than 18 years.

Results: Of the 451 error reports identified, 95% reached the patient, 6.4% reached the patient and necessitated increased monitoring and/or treatment, and 77% involved medications being used off label. Thirty-three percent of errors cited administering as the macrolevel cause of the error, 30% cited dispensing, 28% cited transcribing, and 7.9% cited prescribing. The most commonly cited medications were sertraline (20%), bupropion (19%), fluoxetine (15%), and trazodone (11%). We found no statistically significant association between medication and reported patient harm; harmful errors involved significantly more administering errors (59% vs 32%, p = .023), errors occurring in inpatient care (93% vs 68%, p = .012) and extra doses of medication (31% vs 10%, p = .025) compared with nonharmful errors. Outpatient errors involved significantly more dispensing errors (p < .001) and more errors due to inaccurate or omitted transcription (p < .001), compared with inpatient errors. Family notification of medication errors was reported in only 12% of errors.

Conclusions: Pediatric antidepressant errors often reach patients, frequently involve off-label use of medications, and occur with varying severity and type depending on location and type of medication prescribed. Education and research should be directed toward prompt medication error disclosure and targeted error reduction strategies for specific medication types and settings.