Tenfold Therapeutic Dosing Errors in Young Children Reported to U.S. Poison Control Centers

Barbara Insley Crouch; E. Martin Caravati; Ed Moltz


Am J Health Syst Pharm. 2009;66(14):1292-1296. 

In This Article

Abstract and Introduction


Purpose. Tenfold dosing medication errors reported to U.S. poison control centers in children younger than six years of age were evaluated.
Methods. A retrospective review of all exposures in children younger than six years of age reported to the American Association of Poison Control Centers' data collection system during 2000–04 was conducted. Cases were selected for inclusion if the exposure was an unintentional therapeutic error and if 10-fold dosing error was coded as one of the therapeutic-error scenarios. The specific substance or drug category, patient age and sex, site of exposure, clinical effects, disposition, and outcome were evaluated
Results. A total of 3894 10-fold dosing errors involving a single substance in children younger than six years of age were reported over a five-year period. The site of exposure was most commonly a residence (n = 3609, 92.7%), followed by a health care facility (n = 223, 5.7%) and a school (n = 32, 0.8%). More than half of the exposures occurred in children 12 months of age or younger. When stratified by age, histamine H2- receptor antagonists and metoclopramide were the most common medications involved in exposures in children 12 months of age and younger. Cough and cold preparations and antibiotics were the most commonly involved medications in therapeutic errors in children over age 12 months.
Conclusion. The most common substances involved in 10-fold medication errors reported to U.S. poison control centers were histamine H2-receptor antagonists and metoclopramide. Most exposures occurred in the home and involved children 12 months of age or younger.


The Institute of Medicine has focused much attention on improving the quality of health care and reducing preventable adverse events, including medication errors.[1–3] The frequency of adverse drug events and medication errors varies by study and health care setting. In the hospital setting, the incidence of prescribing errors has ranged from 12.3 to 1400 errors per 1000 admissions, and the prevalence of administration errors has been reported as between 2.4 and 11.1 errors per 100 opportunities or doses.[3]

Children are particularly vulnerable to medication errors because dosing is often weight based and involves decimal points, which increase the opportunity for mistakes. Depending on the definition of "medication error" used, reported rates of medication errors in hospitalized pediatric patients have ranged from 4% to 30%.[3]

Therapeutic errors accounted for 10% of exposures reported to U.S. poison control centers in 2006.[4] Therapeutic errors involve medications or products that are substituted for another medication. The most commonly reported cause of these errors was inadvertently taking or giving a medication twice. Tenfold dosing errors accounted for a smaller but important number of medication errors reported to poison control centers and were more likely to be reported in children younger than age six years.[4] A better understanding of 10-fold dosing errors can help target prevention efforts to reduce these events.

The objective of this study was to characterize 10-fold therapeutic dosing errors in children younger than six years of age reported to U.S. poison control centers.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: