Pediatric Medication Errors

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How much do you trust your doctor’s prescriptions?

A lot? Great, that is ideal. Now – how much do you trust his handwriting? How much do you trust the 22-year-old scribe who transfers the doctor’s charting? And how much do you trust the pharmacist, and the pharmacy tech? With your life, maybe. You are, after all, a fully-fledged adult. But try to picture how comfortable you’d feel when the stakes are a bit higher. 

Try to picture how you’d feel if the prescription was for your child.

Imagine this: your son or daughter has a fever of 102 degrees, and has complained of body aches for the last 5 days. Though lucid, your child has begun to lose energy and is having trouble sleeping. You call into work and arrange time to rush your kid into urgent care.

After a 2-hour wait and a 20-minute exam, the clinic doctor hands you a written prescription for amoxicillin, an antibiotic frequently used to treat bacterial infections in pediatric patients. The doctor notices you look stressed, and mentions casually that these infections are extremely common and curable. You remain unconvinced as your child slumps listlessly on the exam table.

Without a word, you turn to leave and power walk with your child in tow back through the waiting room. A triage nurse calls after you, “The pharmacy is downstairs!” You shepherd your kid into the pharmacy, hoping upon hope that this medicine will help this infection become a distant memory within days. You get to the pharmacy counter, hand over the scrap of prescription paper to the pharmacist. He squints at it for an uncomfortable 10 seconds, then shrugs, and tells you it will be filled in 30 minutes.

Your breath stops.

Among all the fear-ridden moments of this day, this is perhaps the scariest.

If your child is sick, there are medications available to treat a myriad of diseases. But nobody can account for the ever-looming spectre of human error that will conspire to fill that orange prescription bottle with the wrong medication.

Pediatric medication errors are a regularity in clinics across the United States.

We’re not talking about mistakes akin to dispensing 29 pills for a one-month supply.

A study by Harvard Medical Practice reported that just under one-third of adverse drug events (ADEs) in a sample of medicated patients were associated with death or long-term disability.

One Adverse Drug Event Prevention Study found that, overall, approximately 6.5 percent of adult admissions experience ADEs, and one-third of those were due to avoidable medication errors. And this risk only increases with pediatric patients.

Newborns, toddlers, kids, preteens, adolescents and young adults all grow at accelerated rates, as does their ability to metabolize certain medications. These growth spurts require more complex calculations to determine correct medication dosages, which creates more chances for medical negligence.

Indeed, rates of potential ADEs in pediatric patients can range up to 3 times the amount as those for adult patients. These adverse events can involve any link in the chain of labor required to hand over a filled prescription to the patient — ordering, transcribing, dispensing, nurse administering, and patient monitoring.

Research by Kaushal et al. found that, frequently, the chief cause of ADEs (of which there are many) can be traced back to errors made by the prescribing physician. Moreover, the largest proportion of those ADEs were linked to incorrect dosing. With such a systemic problem targeting perhaps the most vulnerable population, the urgency for a solution has never been higher.

Pharmacology Exploded in Popularity in the 1950s

In the decades since then, researchers have had a lot of time to document potential solutions to this problem of rampant medication errors. Among the most effective methods studied in recent years is the digitization of the prescription-writing process. A meta-study of pediatric medication errors found that “computerized provider order entry with clinical decision support” reduced medication errors by a minimum of 36 percent, and a maximum of 87 percent. In other words, patients experienced far fewer avoidable ADEs when clinical decisions were backed by a software safety net designed to correct for the variabilities in individual patients.

All human bodies share obvious biological similarities. But there arises exceptional challenges for physicians when the nuances of an individual’s age, physical development, etc. demand treatments that aren’t typically thought of as appropriate for most patients. This is especially true of fast-developing pediatric patients. With thorough (and costly) implementation, healthcare facilities now have the capability to significantly curb the rates of pediatric medication errors.

However, for many clinics in the U.S., these precautions still have not been implemented, and patients can become victims of antiquated treatment practices. In 2008, healthcare workers in Colorado set a precedent for the largest medical malpractice in the state’s history, owing to a dosage error that left the newborn patient brain damaged and in need of round-the-clock care. According to Reuters, the victim was born with a congenital heart defect, which prompted doctors to schedule reparative surgery 4 days after her birth. Prior to the procedure, the newborn patient received the wrong dose of the drug prostaglandin. Her heart stopped for 33 minutes while medical staff attempted to resuscitate her. The cardiac arrest deprived the patient’s brain of oxygen for such an extent that her brain was irreparably damaged. Children’s Hospital Colorado was eventually found liable for $17.8 million, testifying to the extent of seemingly small mistakes in medicating pediatric patients.

In many ways, the medical risks of ADEs in pediatric patients are magnified many times over. Organ systems are still developing throughout the entire 18 years of pediatric care, which means that harm caused by incorrect dosing or wrongfully-prescribed medications can incur permanent damage. In the case of this Colorado newborn, 1 mistake incurred immeasurable damage to the child and her family. Cases like this illustrate the severe possibilities of a single misstep in pediatric care. Though we all must concede that nothing is 100 percent within our control, you can advocate on your child’s behalf to ensure your doctor, your treatment team, and your healthcare facility assumes the necessary extreme diligence in medicating your child.


  • Coffman, K. (2015, April 04). Family of Colorado infant given wrong DRUG Dose AWARDED $17.8 Million. Retrieved February 12, 2021, from Reuters.
  • Rinke ML, Bundy DG, VELASQUEZ CA, Rao S, Zerhouni Y, LOBNER k, Blanck jf, Miller MR. interventions to Reduce Pediatric MEDICATION errors: A systematic Review. pediatrics. 2014;134(2):338-360. (n.d.). Retrieved February 13, 2021, from Pubmed.
  • Stratton, K., Blegen, M., Pepper, G., & Vaughn, T. (2004, December 25). Reporting of medication errors by pediatric nurses. Retrieved February 12, 2021, from Science Direct.
  • Rinke, M., Bundy, D., Velasquez, C., Rao, S., Zerhouni, Y., Lobner, K., . . . Miller, M. (2014, August 01). Interventions to reduce pediatric medication errors: A systematic review. Retrieved February 13, 2021, from American Academy of Pediatrics.

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