This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (41)  • Contact me when this article is cited  Related Content  • Similar articles in this journal  Topic Collections  • Drug Therapy  • Medication Error  • Alert me on articles by topic  Social Bookmarking   What's this?

Timothy S. Lesar, PharmD

Arch Pediatr Adolesc Med. 1998;152:340-344.

Background  Calculation errors in prescribing are a well-recognized problem; however, no systematic studies of actual errors involving calculation or other errors in the use of drug dosage equations are available.

Objective  To characterize the nature and potential adverse consequences of actual prescribing errors involving dosage equations.

Design  Analysis of the characteristics of 200 consecutive prescribing errors with potentially adverse outcomes involving dosage equations.

Setting  Tertiary care teaching hospital.

Measurements  Potential adverse outcomes, prescribing service, medication class, and the process point at which the error was made.

Results  Errors most commonly involved children (69.5%) and antibiotics (53.5%). Forty-two percent of errors were considered to put the patient at risk for a serious or severe preventable adverse outcome. Errors in decimal point placement, mathematical calculation, or expression of dosage regimen accounted for 59.5% of dosage errors. The dosage equation was wrong in 29.5% of dosage errors.

Conclusions  The use of equations to determine medication dosages presents considerable risk to patients for errant dosing and subsequent adverse events or therapeutic failure. Errors may occur in any component of a dosage equation. Health care organizations should implement procedures to reduce the risk for errors resulting from the use of dosage equations.

From the Department of Pharmacy, Albany Medical Center, Albany, NY.

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Tenfold therapeutic dosing errors in young children reported to U.S. poison control centers
Crouch et al.
Am J Health Syst Pharm 2009;66:1292-1296.
ABSTRACT | FULL TEXT  

Nursing Management of Medication Errors
Luk et al.
Nurs Ethics 2008;15:28-39.
ABSTRACT  

Preparation for Emergencies in the Offices of Pediatricians and Pediatric Primary Care Providers
Committee on Pediatric Emergency Medicine
Pediatrics 2007;120:200-212.
ABSTRACT | FULL TEXT  

Standard Drug Concentrations and Smart-Pump Technology Reduce Continuous-Medication-Infusion Errors in Pediatric Patients
Larsen et al.
Pediatrics 2005;116:e21-e25.
ABSTRACT | FULL TEXT  

Prospective observational study on the incidence of medication errors during simulated resuscitation in a paediatric emergency department
Kozer et al.
BMJ 2004;329:1321.
ABSTRACT | FULL TEXT  

Design of a safer approach to intravenous drug infusions: failure mode effects analysis
Apkon et al.
Qual Saf Health Care 2004;13:265-271.
ABSTRACT | FULL TEXT  

Drug Errors: What Role do Nurses and Pharmacists have in Minimizing the Risk?
Guy et al.
J Child Health Care 2003;7:277-290.
ABSTRACT  

Prioritizing Strategies for Preventing Medication Errors and Adverse Drug Events in Pediatric Inpatients
Fortescue et al.
Pediatrics 2003;111:722-729.
ABSTRACT | FULL TEXT  

Effect of an Intervention Standardization System on Pediatric Dosing and Equipment Size Determination: A Crossover Trial Involving Simulated Resuscitation Events
Shah et al.
Arch Pediatr Adolesc Med 2003;157:229-236.
ABSTRACT | FULL TEXT  

Variables Associated With Medication Errors in Pediatric Emergency Medicine
Kozer et al.
Pediatrics 2002;110:737-742.
ABSTRACT | FULL TEXT  

Large Errors in the Dosing of Medications for Children
Kozer et al.
NEJM 2002;346:1175-1176.
FULL TEXT