Children medication errors

Ghaleb M A, Wong I C K (2006). Medication errors in children. Arch Dis Child Educ Pract 91 20. 

Ross L M, Wallace J, Paton J Y (2000). Medication errors in a paediatric teaching hospital in the UK five years operational experience. Arch Dis Child 83 492-497. 

D Alessandro LC, Rieder MJ, Gloor J, Freeman D, Buffo-Sequiera I. Life-threatening flecainide intoxication in a young child secondary to medication error. Ann Pharmacother 2009 43(9) 1522-7. 

In 1999 there were 2.5 times as many exposures as in 1993. Clonidine was the child s medication in 10% of those under 6 years, 35% of those aged 6-12 years, and 26% of the adolescents. Unintentional overdose was most common in those under 6 years, while therapeutic errors and suicide attempts predominated in those aged 6-12-years and the adolescents. In 6042 symptomatic children (60%), the most common symptoms were lethargy (80%), bradycardia (17%), hypotension (15%), and respiratory depression (5%). Most of the exposures resulted in no effect (40%) or minor effects (39%). There were moderate effects in 1907 children (19%), major effects in 230 (2%), and one death in a 23-month-old child. 

But back to that phone call. The incident it announced was the accidental death of a six-week-old infant. The child had been admitted to our hospital for an initial loading dose of digoxin, a powerful medication that was expected to control his symptoms of early congestive heart failure, but a conversion error from micrograms to milligrams, and a misplaced decimal point written by a distracted medical resident, produced an order for ten times the prescribed amount. That order set in motion a chain of events that transformed a healing medication into a lethal overdose. 

Chedoe I. Molendijk H, Hospes W, Van den Heuvel ER, Taxis K The effect of a multifaceted educational intervention on medication preparation and administration errors in neonatal intensive care. Arch Dis Child Fetal Neonatal Ed 2012 97 F449-F455. 

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