Infants and young children treated with heart drugs get the wrong dose or end up on the wrong end of medication errors more often than older children, according to research led by the Johns Hopkins Children's Center to be published July 6 in Pediatrics.
While the researchers found the highest number of errors among infants under the age of 1, they say children of all ages are vulnerable to such mistakes because health-care providers can manually miscalculate weight-sensitive doses and can misinterpret safe age ranges of adult drugs used off-label in children.
"We found that cardiac medication errors happen in children, and they can happen every step of the way, from prescribing to delivering the medication, but dosing and administration errors were ominously common," says lead investigator Marlene Miller, M.D., M.Sc., vice chair for quality and patient safety at Hopkins Children's.
The researchers emphasize that the vast majority of errors analyzed in their study 96 percent were benign and caused no detectable harm to patients or never reached the patients, but in 4 percent (31) of the cases there was harm, although no deaths.
The report and the warnings were drawn from a study analyzing 821 medication errors submitted to a national voluntary error-reporting database. As Miller noted, errors occurred every step of the multiple-step process of calculating dosages, prescribing, dispensing and giving drugs, with the most common causes of dosing errors attributed to misinterpretation of the patient's weight, mathematical errors of computation, misinterpretation of orders, giving extra doses or missing doses. In one instance, the patient's weight in pounds was mistaken for weight in kilograms, resulting in a gross overdose of three different heart drugs, which sent the patient into cardiac arrest.
Half of the errors occurred in children younger than 1 year, and 90 percent involved children under the age o
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