errors

Infants Regularly Given Adult Doses of Heart Disease Drugs

Monday, July 20, 2009 by: Michael Jolliffe
Tags: infants, health news, Natural News

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(NaturalNews) Babies and young children are being given adult doses of common heart disease drugs, and often the wrong medication, according to research conducted by the Johns Hopkins Children's Center in Baltimore.

A study headed by Marlene Miller, M.D., M.Sc., vice chair for quality and patient safety at the institution discovered that drugs given for a congenital heart condition, effecting around one in every thousand newborns, were commonly given at substantially higher doses than intended, or in error.

"We found that cardiac medication errors happen in children, and they can happen every step of the way, from prescribing to delivering the medication, but dosing and administration errors were ominously common", wrote Dr Miller in an article to be published in the July 2009 edition of the journal Pediatrics.

Researchers reviewed a national medical error database and found that half of errors occurred in children younger than 1 year, and 90 percent involved children under the age of 6 months.

Findings revealed that errors occurred in each step of the treatment process, from calculating dosages, through prescribing and dispensing to finally administering medication.

Treatment mistakes led to a variety of potentially dangerous outcomes, most often due to extra or missing medication doses, while a number of errors occurred through incorrect recordings of the child's weight. In one instance, a patient's weight in pounds was noted to have been mistaken for weight in kilograms, resulting in a severe overdose of three different heart drugs, sending the child patient into cardiac arrest.

Also published this month are the results of a study led by researchers at the University of Utah into 'ten-fold' medication errors in children, meaning drug dosing errors in which the given dose was more or less than ten times the correct clinical dose. Nearly 4000 10-fold dosing errors involving just a single substance were reported over a five-year period, mostly in children aged 12 months or younger. [2]

Other studies have come to similar conclusions. In 2006, Rinke and colleagues, also at Johns Hopkins (School of Medicine), reviewed medical error reporting databases relating to mistakes in childhood chemotherapy. The research team found 310 errors across 5 years (1999-2004), 85% of which were potentially harmful, with Methotrexate being the drug used most erroneously.

"Investigation is needed regarding targeted medication administration safeguards for these high-risk medications", concluded the authors in a study published by the journal Cancer. [3]

Similarly, Hicks and colleagues at the The USP Center for the Advancement of Patient Safety in Rockville, Maryland reviewed the MEDMARX medical database to gain a more general understanding of the frequency of pediatric medical errors. 816 harmful outcomes involving 242 medications were identified during a 5-year review period.

The team reported that "wrong dosing and omission errors were common", resulting in a "substantial number of harmful pediatric medication errors". [4]

Alexander et al. Cardiovascular medication errors in children. PEDIATRICS. 2009 Jul;124(1): 324-332 (doi:10.1542/10.1542/peds.2008-2073). [1]
Crouch et al. Tenfold therapeutic dosing errors in young children reported to U.S. poison control centers. Am J Health Syst Pharm. 2009 Jul 15;66(14):1292-6. [2]
Rinke et al. Characteristics of pediatric chemotherapy medication errors in a national error reporting database. Cancer. 2007 Jul 1;110(1):186-95. [3]
Hicks et al. Harmful medication errors in children: a 5-year analysis of data from the USP's MEDMARX program. J Pediatr Nurs. 2006 Aug;21(4):290-8. [4]


About the author

Michael Jolliffe is a freelance writer based in Oxford, UK.

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