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Preventing Medication Errors: Quality Chasm Series (2007)
Board on Health Care Services (HCS)

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. "3 Medication Errors: Incidence and Cost ." Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007.

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Preventing Medication Errors

TABLE 3-5 Errors in Hospital Pediatric Care

Medication ordering errors

Percentage of prescriptions containing an error

4.2 (Kaushal et al., 2001)

24 (Fontan et al., 2003)

Medication ordering errors in pediatric intensive care

Percentage of prescriptions containing an error

30 (Potts et al., 2004)

Administration errors

Per 100 orders

0.72 (Kaushal et al., 2001)

Administration errors in pediatric nephrology units

Per 100 opportunities for error

23 (Fontan et al., 2003)

Emergency department prescribing errors

Per 1,000 patients

100 (Kozer et al., 2002)

Emergency department administration errors

Per 1,000 patients

39 (Kozer et al., 2002)

Emergency department acetaminophen doses ordered outside recommended range

Per 100 doses ordered

22 (Losek, 2004)

errors and 39.0 administration errors occurred in the emergency department per 1,000 pediatric patients (Kozer et al., 2002). The other study found that 22.0 percent of acetaminophen doses ordered were outside the recommended 10–15 milligrams/kilogram recommendation for these patients (Losek, 2004). (See Table 3-5 for a summary of errors in hospital pediatric care).

Finally, a recent study found that potential medication errors occur frequently in outpatient pediatric clinics (McPhillips et al., 2005). In a sample of new prescriptions for 22 common medications, approximately 15 percent of children were dispensed a medication with a potential dosing error.

Psychiatric Care

Many studies of medication errors associated with psychotropic medications either were conducted as part of larger general medical–surgical studies or other ADE-reporting databases, or were restricted to geriatric populations in nonpsychiatric restricted settings, such as nursing homes and ambulatory clinics. The one major study devoted exclusively to medication errors in psychiatric care found a very high rate of errors in a state

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