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

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 2000-2004 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 (107 238 cases, 45%). The majority of errors were due to excessive dosing (171 238, 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 systemic process changes.