least 1 invalid dose (Butte et al., 2001). A second study, also conducted in the United States, estimated 21 percent of children being overimmunized for at least one vaccine (Feikema et al., 2000). A third study reported on calls regarding vaccines to the National Poison Control Registry in Greece. The estimate of 11 vaccine errors per 1 million immunization doses likely represents significant underreporting since one would have to consider a vaccine dose to be a poisoning to call this registry (Petridou et al., 2004).

Of the two emergency department studies, one focused on global estimates of prescription and administration errors in this setting, and the other on medication errors with respect to antipyretics (see Table C-23). The first study estimated a rate of 100 prescribing errors per 1,000 patients and 39 administration errors per 1,000 patients (Kozer et al., 2002). The second study found that 22 percent of acetaminophen doses ordered were outside of the recommended 10–15 milligrams/kilogram dose (Losek, 2004).

Incidence of ADEs During Hospitalization

A prospective study analyzed 1,120 patients at two academic pediatric institutions during 1999 using chart, medication order sheet, and medication administration record review, as well as voluntary and solicited reports (Kaushal et al., 2001) (see Table C-24). Twenty-six ADEs were identified—

TABLE C-23 Emergency Department Pediatric Care: Prescription and Administration Errors

Prescribing errors

Errors per 1,000 patients—detection method

100 (Kozer et al., 2002)—chart review

Administration errors

Errors per 1,000 patients—detection method

39 (Kozer et al., 2002)—chart review

Acetaminophen doses ordered outside recommended range

Percentage of doses ordered outside recommended range—detection method

22 (Losek, 2004)—chart review

TABLE C-24 Hospital Care: Pediatric ADE Incidence During Hospitalization


ADEs per 100 Admissions

ADEs per 1,000 Patient-Days

Proportion of ADEs Preventable

Kaushal et al., 2001



19 percent (out of 26 ADEs in the study)

Holdsworth et al., 2003



(76 ADEs in the study)

The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement