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1 child every 8 minutes experiences an out-of-hospital medication error

Among children less than 6 years of age, one child every eight minutes experiences an out-of-hospital medication error annually, finds a new study, which analyzed data from the National Poison Data System from 2002 to 2012.

Among children less than 6 years of age, one child every eight minutes experiences an out-of-hospital medication error, found a study in Pediatrics released online today.

The study analyzed reports to the National Poison Data System from 2002 to 2012. During this time, Poison Control Centers in the United States recorded 696,937 out-of-hospital medication error exposures among children less than 6 years of age, which averages to 63,358 exposures annually. Almost 97 percent of the children were exposed at home.

The rate of medication errors was highest among children less than a year of age, accounting for more than one fourth of the incidents. More than 80 percent of the medication errors involved liquid formulations.

Types of medication errors included:

  1. Inadvertently taking or being given medication twice

  2. Incorrect dose

  3. Confused units of measure

  4. Wrong medication taken or given

Pain relievers, cough and cold preparations, antihistamines, and antimicrobial agents, were the major categories of medications involved with medication errors. Although 94 percent of the medication error episodes did not receive treatment. 1,899 were admitted to a critical care unit and there were 25 deaths. Pain relievers accounted for 40 percent of the deaths.

Cough and cold medication errors declined significantly starting in 2005. But errors significantly increased in others areas, such as dietary supplements/herbals/homeopathics, cardiovascular drugs, and pain relievers.

The PROTECT Initiative, developed by the Centers for Disease Control and Prevention, in collaboration with leaders from industry, academia, professional organizations, and health agencies, has outlined priorities to prevent both medication errors and unsupervised ingestions. These include an educational campaign and refining dosing measures and instructions on medication packaging and labeling; using only milliliters as a measure for liquid medications; using leading zeros before a decimal point, and not using trailing zeros after a decimal point; using only kilograms for patient weights; and conversion of single ingredient over-the-counter medications to a single concentration, such as what manufacturers voluntarily did with liquid acetaminophen.

For parents and guardians of children less than six years of age, here are some tips to reduce out of hospital medication errors:

  1. Have a system in place for remembering if and when a medication dose is administered or taken.  This can be as simple as checking off a box on a calendar, or setting an alarm using a smart phone.

  2. Know your child's weight in kilograms. Almost all medication dosages are calculated based on kilogram weights. Weight in pounds divided by 2.2 equals weight in kilograms.

  3. Remember the equivalent in milliliters of common measures of volume: one teaspoon equals 5 milliliters, one tablespoon equals 15 milliliters.

  4. Check every written prescription, and clarify unclear information with the prescriber or the pharmacist.

  5. Do not over treat fever with pain relievers, and common colds with cough and cold preparations or anti-histamines.

Once you recognize that a medication error has occurred, contact your local Poison Control Center immediately by calling 1-800-222-1222.

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