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Incidence and Nature of Dosing Errors in Paediatric Medications

A Systematic Review

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Abstract

In paediatric medicine, drug doses are usually calculated individually based on the patient’s age, weight and clinical condition. Therefore, there are increased opportunities for, and a relatively high risk of, dosing errors in this setting. Consequently, a systematic literature review using several databases was conducted to investigate the incidence and nature of dosing errors in children; 16 studies were found to be relevant.

Eleven of the 16 studies found that dosing errors are the most common type of medication error, three of the remaining studies found it to be the second most common type. This review of published research on medication errors therefore suggests that dosing errors are probably the most common type of error in the paediatric population. In addition, there was a great variation in the error rates reported; this is likely to be due to the differences in the medication error definitions and methodologies employed. For example, the dosing error rate determined using spontaneous reporting ranges from 0.03 per 100 admissions in the UK to 2 per 100 admissions in the US. Extrapolating this, if the under-reporting rate is about 1 in 100, then the true incidence would be around 50 000 paediatric dosing errors per year in England.

The information available shows that dosing errors are not uncommon and that 10-fold overdoses caused by calculation errors have led to serious consequences. There is an urgent need to develop methods to reduce medication errors in children and dosing errors should be the first priority.

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Acknowledgements

Dr Ian Wong is funded by the UK Department of Health, National Public Health Career Scientist Award. Miss Maisoon Abdullah Ghaleb is partly funded by the UK Overseas Research Scholarship. Professor Nick Barber, Drs Bryony Dean Franklin and Ian Wong have received funding from the UK Medical Research Council and UK Department of Health in the research of medication errors and the use of technology in their reduction.

The authors have no conflicts of interest that are directly relevant to the content of this review.

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Authors and Affiliations

  1. Centre for Paediatric Pharmacy Research, The School of Pharmacy, University of London & the Institute of Child Health, University College London, Bloomsbury, 29/39 Brunswick Square, London, WC1N 1AX, UK

    Ian C.K. Wong & Maisoon A. Ghaleb

  2. The Department of Practice and Policy, The School of Pharmacy, University of London, London, UK

    Maisoon A. Ghaleb & Nick Barber

  3. Academic Pharmacy Unit, Hammersmith Hospitals NHS Trust, London, UK

    Bryony D. Franklin

Authors
  1. Ian C.K. Wong
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  2. Maisoon A. Ghaleb
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  3. Bryony D. Franklin
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  4. Nick Barber
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Correspondence to Ian C.K. Wong.

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Wong, I.C., Ghaleb, M.A., Franklin, B.D. et al. Incidence and Nature of Dosing Errors in Paediatric Medications. Drug-Safety 27, 661–670 (2004). https://doi.org/10.2165/00002018-200427090-00004

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