Severe injury or death in young children from therapeutic errors: A summary of 238 cases from the American Association of Poison Control Centers

Leah S Tzimenatos, G. Randall Bond

Research output: Contribution to journalArticle

29 Citations (Scopus)

Abstract

Introduction. Medication-related errors pose a risk to children, but accurate data regarding errors with clinically significant outcomes are not available. We attempt to describe errors, identify patterns of error, and find targets for prevention using a large series of pediatric therapeutic errors with severe outcomes. Methods. A national, retrospective poison center chart review study including all cases of severe injury or death from therapeutic error involving children less than 6 years which were reported to the American Association of Poison Control Centers from 20002004 was performed.Results. Among 272 cases identified, 238 were included in analysis and 34 were excluded; 162 cases occurred in the home and 70 in health care facilities. Significant errors disproportionately affected children less than 1 year (107238 cases, 45). The majority of errors were due to excessive dosing (171238, 72). Common mechanisms of error were identified: 10-fold errors, confusion about formulation or units of measure, increased frequency, and adult dosing.Conclusions. The recurring circumstances underlying many of these errors suggest that preventing such errors may require systemicprocess changes.

Original languageEnglish (US)
Pages (from-to)348-354
Number of pages7
JournalClinical Toxicology
Volume47
Issue number4
DOIs
StatePublished - 2009
Externally publishedYes

Fingerprint

Poison Control Centers
Poisons
Wounds and Injuries
Medication Errors
Health Facilities
Therapeutics
Pediatrics
Delivery of Health Care
Health care

Keywords

  • Age group
  • Death
  • Dispensing error
  • Drug

ASJC Scopus subject areas

  • Toxicology
  • Medicine(all)

Cite this

@article{884734b6fa5e4c0ebb5b7922432d13bc,
title = "Severe injury or death in young children from therapeutic errors: A summary of 238 cases from the American Association of Poison Control Centers",
abstract = "Introduction. Medication-related errors pose a risk to children, but accurate data regarding errors with clinically significant outcomes are not available. We attempt to describe errors, identify patterns of error, and find targets for prevention using a large series of pediatric therapeutic errors with severe outcomes. Methods. A national, retrospective poison center chart review study including all cases of severe injury or death from therapeutic error involving children less than 6 years which were reported to the American Association of Poison Control Centers from 20002004 was performed.Results. Among 272 cases identified, 238 were included in analysis and 34 were excluded; 162 cases occurred in the home and 70 in health care facilities. Significant errors disproportionately affected children less than 1 year (107238 cases, 45). The majority of errors were due to excessive dosing (171238, 72). Common mechanisms of error were identified: 10-fold errors, confusion about formulation or units of measure, increased frequency, and adult dosing.Conclusions. The recurring circumstances underlying many of these errors suggest that preventing such errors may require systemicprocess changes.",
keywords = "Age group, Death, Dispensing error, Drug",
author = "Tzimenatos, {Leah S} and Bond, {G. Randall}",
year = "2009",
doi = "10.1080/15563650902897650",
language = "English (US)",
volume = "47",
pages = "348--354",
journal = "Clinical Toxicology",
issn = "1556-3650",
publisher = "Informa Healthcare",
number = "4",

}

TY - JOUR

T1 - Severe injury or death in young children from therapeutic errors

T2 - A summary of 238 cases from the American Association of Poison Control Centers

AU - Tzimenatos, Leah S

AU - Bond, G. Randall

PY - 2009

Y1 - 2009

N2 - Introduction. Medication-related errors pose a risk to children, but accurate data regarding errors with clinically significant outcomes are not available. We attempt to describe errors, identify patterns of error, and find targets for prevention using a large series of pediatric therapeutic errors with severe outcomes. Methods. A national, retrospective poison center chart review study including all cases of severe injury or death from therapeutic error involving children less than 6 years which were reported to the American Association of Poison Control Centers from 20002004 was performed.Results. Among 272 cases identified, 238 were included in analysis and 34 were excluded; 162 cases occurred in the home and 70 in health care facilities. Significant errors disproportionately affected children less than 1 year (107238 cases, 45). The majority of errors were due to excessive dosing (171238, 72). Common mechanisms of error were identified: 10-fold errors, confusion about formulation or units of measure, increased frequency, and adult dosing.Conclusions. The recurring circumstances underlying many of these errors suggest that preventing such errors may require systemicprocess changes.

AB - Introduction. Medication-related errors pose a risk to children, but accurate data regarding errors with clinically significant outcomes are not available. We attempt to describe errors, identify patterns of error, and find targets for prevention using a large series of pediatric therapeutic errors with severe outcomes. Methods. A national, retrospective poison center chart review study including all cases of severe injury or death from therapeutic error involving children less than 6 years which were reported to the American Association of Poison Control Centers from 20002004 was performed.Results. Among 272 cases identified, 238 were included in analysis and 34 were excluded; 162 cases occurred in the home and 70 in health care facilities. Significant errors disproportionately affected children less than 1 year (107238 cases, 45). The majority of errors were due to excessive dosing (171238, 72). Common mechanisms of error were identified: 10-fold errors, confusion about formulation or units of measure, increased frequency, and adult dosing.Conclusions. The recurring circumstances underlying many of these errors suggest that preventing such errors may require systemicprocess changes.

KW - Age group

KW - Death

KW - Dispensing error

KW - Drug

UR - http://www.scopus.com/inward/record.url?scp=67649239433&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=67649239433&partnerID=8YFLogxK

U2 - 10.1080/15563650902897650

DO - 10.1080/15563650902897650

M3 - Article

C2 - 19514883

AN - SCOPUS:67649239433

VL - 47

SP - 348

EP - 354

JO - Clinical Toxicology

JF - Clinical Toxicology

SN - 1556-3650

IS - 4

ER -