One of the challenges of being a pediatrician is ensuring that our young patients are medicated correctly. The process of weight-based dosing is fraught with potential mistakes because it involves several step calculations—the weight of the child, the dosage of the medication, the concentration of the medication, and the dosing interval. Medication errors are all too common in pediatric practice, no matter where medication is administered to children— hospital, home, or office. This article will describe many of the hazards of pediatric prescribing and detail the many ways pediatricians can avoid medication missteps.
“Death by decimal point”
According to a recent article, as many as 27% of all pediatric medication orders result in a medication error.1 Medication errors fall into 3 categories—prescribing errors, dispensing errors, and administration errors—and each of these categories are associated with interventions that can reduce, but not eliminate, medication errors.
Poor handwriting as well as misunderstood abbreviations, calculation errors, and misplaced decimal points are all examples of “prescribing errors.” Whereas over-the-counter (OTC) acetaminophen is universally available in a concentration of 160 mg/5 mL, OTC ibuprofen is available in concentrations of 50 mg/1.25 mL as well 100 mg/5 mL. So it is easy for parents to administer the wrong dose of ibuprofen if practitioners communicate only the volume of the ibuprofen without specifying the concentration.
Many of our prescription medications come in varying concentrations. For example, prescription prednisolone liquid comes in concentrations of 5 mg/5 mL, 10 mg/5 mL, 15 mg/5 mL, 20 mg/5 mL, and 25 mg/5 mL, and rushed pediatricians can easily prescribe the incorrect dose of prednisolone if they think in milliliters rather than milligrams. We must remember to avoid the use of terminal zeros in our prescriptions and always include a number to the left of the decimal point (Table).
Additionally, because medication abbreviations are confusing (MS may mean morphine sulfate or magnesium sulfate, for example, the American Academy of Pediatrics (AAP) recommends that pediatricians avoid abbreviations altogether and write out medication names and instructions clearly. Physicians also should use generic names to avoid brand confusion names, and spell out units (eg, use milligrams rather than mg).2
Also contributing to medication errors are varying dosages based on the indication (different dosages for respiratory infections vs meningitis for many antibiotics, for example) and a general unawareness of the maximum adult dose on the part of pediatricians. The AAP, therefore, recommends that pediatricians indicate the patient weight and milligram/kilogram dose on medication orders and prescriptions to enable pharmacists to more easily check the accuracy of prescribed medication doses.2