Illustrative Cases of Medication Errors in the Pediatric ED

SeverityErrors in Drug AdministrationPrescribing Errors
Insignificant/minimal risk error: minimal likelihood of harmCodeine 30 mg orally given to a child with postoperative pain without a doctor’s orderSalbutamol for a child with asthma, dose not specified
Dimenhydrinate 24 mg given instead of 20 mgTrimethoprim orally for urinary tract infection ordered 9 mg/kg/d instead of 1–2 mg/kg/d
Dexamethasone given to a child with reactive airway disease without a physician orderDimenhydrinate ordered every 4 h instead of every 6 h, dose 6.8 mg/kg/d instead of 5 mg/kg/d
Cefazolin intravenously ordered every 8 h but given every 6 hClarithromycin 15 twice daily ordered, units not specified
Cefuroxime 470 mg (75 mg/kg, recommended dose 25 mg/kg) 3 times a day for a child with pneumonia
Significant error: an error that could cause non-life-threatening consequences, or an error that would result in a less effective treatment for the child’s conditionPrednisone ordered for a child with asthma but was not givenAcetaminophen 15–20 mg/kg every 4 h for a febrile toddler (daily dose 90–120 mg/kg)
Morphine intravenously given, dose not specifiedAmoxicillin 40 mg (instead of 400 mg) tid for a 25-kg child with otitis media
Salbutamol by inhalation ordered 3 times but given 12 timesCefuroxime 1 g ordered every 24 h (recommended every 8 h) for a 26-kg child (no known renal disease)
Clindamycin ordered for a child with skin infection but not givenValproic acid ordered, no dose specified
Salbutamol inhaler prescribed 2 puffs every hour for use at home
Severe error: an error that could cause death or decrease the chance of successful treatment of a life-threatening conditionCefotaxime not given for a patient with meningitisMorphine in the correct dose ordered every 30 min as needed for a child with supracondylar fracture