Tenfold therapeutic dosing errors in young children reported to U.S. poison control centers

Crouch, Barbara Insley; Caravati, E. Martin; Moltz, E. D.

doi:10.2146/080377

Cited by 18 publications

(13 citation statements)

References 12 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Analgesics and antibiotics were the commonest ME in our study, as reported by others [3,6,8,9,[11][12][13][14]. Vitamin D was also common, unlike other studies from the USA, Ireland, Australia and France [3,11,12,14].…”

Section: Discussionsupporting

confidence: 65%

“…Several studies from poison centres on ME were published over the years [3][4][5][6][7][8][9][10][11][12][13][14][15], and most were retrospective [4][5][6][7][8][9][10][11]13,15]. Some evaluated only specific age groups, young children [3,7,12,13] and elderly patients [8,9]. Some studies concentrated on iatrogenic errors and did not report any ME outside healthcare facilities [4,5,10].…”

mentioning

confidence: 99%

See 1 more Smart Citation

Medication Errors Outside Healthcare Facilities: A National Poison Centre Perspective

Lavon

Ben-Zeev

Bentur

2013

Basic Clin Pharma Tox

View full text Add to dashboard Cite

Medication errors (ME) are a major concern to healthcare systems. Most studies evaluated ME occurring in healthcare facilities; only few focused on ME outside them. The objective was to characterise ME occurring outside healthcare facilities. A prospective observational follow-up study evaluating all ME occurring outside healthcare facilities reported to a national poison information centre during a 5-month period. For each ME case, a detailed questionnaire was filled and a follow-up call was made within 7 days. The collected data included demographics, circumstances, type of error and outcome. Of 1381 consecutive ME cases were included; 97.8% involved a single incident and 88.3% one drug. The main characteristics of the ME were as follows: children younger than 6 years old (58.9%), parents responsible for 55.6% of cases, wrong dose 34.5% and different medication 30.1%. Analgesics (27.4%) and antimicrobials (12.2%) were the most common pharmaceuticals. The main reasons for the ME were look-alike packaging (31.4%) and misunderstood instructions (28%). Most followed up patients (97.1%) were asymptomatic or mildly affected; there was one severe case and no mortality. Most ME occurring outside healthcare facilities are single incidents, involving young children who were administered a wrong dose or medication due to look-alike packaging or misunderstood instructions with asymptomatic or mild outcome. Improved packaging, labelling and patient education are suggested to reduce ME.Medication errors (ME) are a major cause of morbidity and mortality [1]. In the USA, the estimated annual death toll of ME is 98,000 cases [2]. While most research on ME is conducted in healthcare facilities, there is limited information on ME occurring in the patients' home. Data collection on patient behaviour and use of medications in the home is difficult and inconsistent. Poison centres serve the general public and record relevant data on ME reported by the public. Several studies from poison centres on ME were published over the years [3][4][5][6][7][8][9][10][11][12][13][14][15], and most were retrospective [4][5][6][7][8][9][10][11]13,15]. Some evaluated only specific age groups, young children [3,7,12,13] and elderly patients [8,9]. Some studies concentrated on iatrogenic errors and did not report any ME outside healthcare facilities [4,5,10]. Shah and Barker published a retrospective study with no follow-up on ME occurring outside hospitals [11]. A more comprehensive assessment of ME in the public may improve our understanding of the characteristics and origin of such errors and lay the ground for preventive measures. The objective of our study was to characterise ME occurring outside healthcare facilities. MethodsWe conducted a prospective observational follow-up study of all ME outside healthcare facilities reported to the Israel National Poison Information Center (IPIC) between 1 August and 31 December 2008. The IPIC serves a population of 7,956,000 people [16]. This is the only national poison information centre in the...

show abstract

Section: Discussionsupporting

confidence: 65%

mentioning

confidence: 99%

Medication Errors Outside Healthcare Facilities: A National Poison Centre Perspective

Lavon

Ben-Zeev

Bentur

2013

Basic Clin Pharma Tox

View full text Add to dashboard Cite

show abstract

“…Medication errors committed by the patient/caregiver have been extensively reported by several studies [3,4]. A study reported 41 % medication errors based on dosing where counseling provided by the healthcare professionals and provision of dosing tools were helpful in reducing the dosing errors [5].…”

Section: Introductionmentioning

confidence: 99%

Inappropriateness of medication use and associated health risks: A cross-sectional study from Pakistan

et al. 2018

View full text Add to dashboard Cite

“…Many par ents are faced with the daily chal lenge of get ting their chil dren to take a med i cine [4]. Re cent find ings in di cate that many ad verse drug events in pe di at ric out pa tients can be at trib uted to er rors in dose cal cu la tion and im proper ad min is tra tion [5,6]. The in ac cu rate dose of the med i cine can thwart the ben e fits of even the most pow er ful drug re sult ing in sub-ther a peu tic un der-dosing, ad verse drug events due to over dos ing, and in ad e quate du ra tion of treat ment as a result of over dos ing [3].…”

Section: Introductionmentioning

confidence: 99%

Appropriate use of oral drops: perception of health professionals and assessment of package insert information

Zaid

Al-Ramahi

Ghoush³

2010

View full text Add to dashboard Cite

Ap pro pri ate use of oral drops Ab stract. Ob jec tives: To eval u ate the per cep tion of health pro fes sion als and in dustry per son nel to wards the ap pro pri ate use of oral drops and to as sess their pack age in serts with re gard to pres ence of proper in struc tions for use and stor age. Meth ods: The first part was a cross-sec tional self-ad min is tered question naire. The ques tion naires were dis tributed ran domly to phy si cians, phar ma cists and de ci sion mak ers in lo cal phar ma ceu ti cal compa nies. In the sec ond part, the pack age in serts of med i ca tions with oral drops were re viewed to check for pres ence of proper in struc tions for stor age and proper use. Re sults: The major ity of phy si cians and phar ma cists (73.3% and 71.2%) thought that oral drops can be deliv ered from the drop per di rectly into the patient's mouth. 60.8% of phy si cians and 54.3% of phar ma cists thought that the drop per should be clamped ver ti cally when oral drop are dis pensed. 72.7% of in dus try per son nel agreed that the an gle of in cli na tion af fects the drop size. Many of these per son nel said their com pa nies did not per form the rec om mended tests for dose uni for mity and cal i bra tion. Instruc tions for stor age and proper use were not avail able in pack age in serts of many oral drop prod ucts in Pal es tine. Con clu sions: Health pro fes sion als should have com plete and correct in for ma tion re gard ing all fac tors that affect the proper de liv ery of oral drops and should coun sel pa tients on the proper method of de liv ery. Phar ma ceu ti cal com pa nies should take into con sid er ation the for mu la tion is sues that may af fect drop size and pro vide leaf lets and la bels with com plete and cor rect in structions on the proper use and stor age of oral drops. Pack age in sert in for mation in oral drops needs to be more com prehensive with re gard to in struc tions for use and stor age.

show abstract

Tenfold therapeutic dosing errors in young children reported to U.S. poison control centers

Abstract: The most common substances involved in 10-fold medication errors reported to U.S. poison control centers were histamine H(2)-receptor antagonists and metoclopramide. Most exposures occurred in the home and involved children 12 months of age or younger.

Cited by 18 publications

References 12 publications

Medication Errors Outside Healthcare Facilities: A National Poison Centre Perspective

Medication Errors Outside Healthcare Facilities: A National Poison Centre Perspective

Inappropriateness of medication use and associated health risks: A cross-sectional study from Pakistan

Appropriate use of oral drops: perception of health professionals and assessment of package insert information

Contact Info

Product

Resources

About