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Pediatric weight-based dosing errors Although children are prescribed medications in 30 to 50 percent of clinic visits, little is known about medication errors in ambulatory pediatrics. A recent study published by the National Library of Medicine found a number of potential problems, including prescribing medication that is not labeled for use in children, discrepancies in published dosing recommendations for many medications, unclear guidelines on use of adult dosing recommendations for children of different ages and weights, and the lack of readily available documented weights to determine appropriate weight-based doses for children.
More is known about medication errors in hospitalized patients than in outpatient settings. Errors in medication ordering are the most common cause of preventable adverse drug events in hospitalized patients. In one adult study, half of all preventable adverse drug events occurred at the physician ordering stage, and the most common type of error was in medication dosing. These errors occurred at a higher rate in children than in adults. The Institute of Medicine (IOM) report on error in medicine dosing identified computerization as an important patient safety strategy. Computerized order entry, combined with advanced decision support systems, has been shown to reduce prescribing errors in hospital settings across many different drug classes. The majority of outpatient settings do not currently use electronic prescription ordering or clinical decision support tools, and few studies have attempted to demonstrate the effectiveness of computerized prescription ordering on reducing medication errors and adverse drug events in ambulatory settings. Published sources of pediatric dosing information differ in their recommendations for dosing ranges for children, sometimes by as much as a twofold difference in the maximum recommended dose. Furthermore, weight-based dosing often encompasses large ranges, sometimes as much as fourfold differences between the minimum and maximum recommended dose. Determining medication dosing errors in children is only possible with accurately documented weightin kilograms. If a provider had meant to prescribe 25 mg/kg/day, but inadvertently calculated the dose based on pounds instead of kilograms (thereby prescribing 2.2 times more medication than he or she meant to prescribe), potentially no error would be detected due to the fact that this dose would still fall well within the recommended range. Many medications that are used for children are most appropriately prescribed by calculating a weight-based dose in total milligrams per kilogram per day. In order to appropriately prescribe these medications, practitioners need an accurate weight. Ideally, weights would always be recorded in kilograms to avoid errors in converting pounds into kilograms when calculating medication doses; however, parents are often interested in their child's weight in pounds. In clinic visits, weights are therefore often measured and recorded in pounds in the medical record. Most retail pharmacies do not mandate inclusion of the child's weight on written prescriptions, making it Accurate weights matter There is tremendous variation in normal weights for young children and extrapolation of a weight by age is likely to be inaccurate. In order to correctly prescribe medications, practitioners need an accurate weight. With that, they can provide the most effective dosage recommendations.
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Tenfold dosing errors in children can easily occur by misplacing a decimal point or by a trailing zero. For example, a 1.0 mg dose may be misread as a 10 mg dose and not recognized as an error by pharmacists as the 10 mg dose is still within the range of adult doses for the medication. In addition, health care providers must be aware of both pediatric dosing recommendations (to calculate a weight-based dose in mg/kg/day) and adult dosing recommendations (to ensure they do not exceed the maximum recommended adult dose in mg/day).