Kozer Eran, Scolnik Dennis, Jarvis Anna D, Koren Gideon
Division of Pediatric Emergency Medicine, the Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
Drug Saf. 2006;29(2):169-74. doi: 10.2165/00002018-200629020-00007.
Tenfold errors in calculation of paediatric drug doses are often life threatening. The magnitude and characteristics of this phenomenon have not been fully described.
The objective of this study was to describe the incidence and nature of paediatric tenfold errors and to describe the effect of different detection approaches on the detection of such errors.
To evaluate the incidence of tenfold errors, data were collected from three different studies on medication errors all conducted at a large tertiary care paediatric hospital: (i) a study investigating medication event reports to the hospital's Medication Incident Committee; (ii) a study auditing the charts of 1532 patients in the emergency department (ED) and; (iii) a prospective study of medication errors occurring during mock code resuscitations in the ED.
In the first study, 20 tenfold errors were reported during the surveyed period. Almost all errors were prescribing errors. The calculated incidence was 1 per 22 500 doses prescribed. In chart auditing study in the ED, two tenfold errors where found in 1678 orders. In the prospective study, four tenfold errors were identified in eight mock resuscitations (125 orders for drugs).
The incidence of tenfold errors in paediatrics varies dramatically when different detection approaches are used. The rate of tenfold errors may be especially high in resuscitation situations and is underestimated by spontaneous reporting.
