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Review Article
Medication errors and its
implications in pediatric dentistry
Shivayogi M. Hugar, M. Suganya, M. Vikneshan, K. Kiran
Department of Pedodontics and Preventive Dentistry, KLES’s VK Institute of Dental Sciences, Belgaum,
Karnataka, India

ABSTRACT

The medication errors compromise the confidence of patients’ in the health‑care system and
lead to increased health‑care cost. Therefore, the medication errors should be minimized as far
as possible and the nature should be identified so that effective systems can be implemented
for prescribing, transcribing, dispensing and administering the medications. This article
reviews the various medication errors that can happen and its causes, the precautions to
be taken for pediatric age groups and prevention of medication errors.

Key words: Adverse drug events, children, computerized physician order entry, medication errors

Introduction or administration of a drug, irrespective

Address for Correspondence:
Dr. Shivayogi M Hugar,
Department of Pedodontics and
Preventive Dentistry, KLES’s VK Institute
of Dental Sciences, Nehru Nagar,
Belgaum ‑ 590 010, Karnataka, India.
E‑mail: dr.hugarsm@gmail.com
Date of Submission: 24‑03‑2013
 Date of Acceptance: 10-08-2013
Access this article online
Website:
www.indjos.com
DOI:
10.4103/0976-6944.129946
Quick Response Code:
Indian Journal of Oral Sciences  Vol. 5  Issue 1  Jan-Apr 2014
Medications are an amazing discovery.
They promote healing, reduce suffering
and contribute to modern medical miracles.
However, because thousands of new drugs
have been developed recently because the
health‑care environment is increasingly
complex and because the patients are often
sicker, there is increasing risk for medication
errors.[1]
Until 27% of all hospital prescribing errors
can be attributed to incomplete medication
histories at the time of admission Accurate
medication histories at the time of hospital
admission are an important element of
medication safety.[2]
The use of medicines in children is
different to adults. Many medicines used
for pediatric patients are either off‑label
or unlicensed. The formulation of many
medicines is appropriate for adults, but not
for pediatric patients, therefore making age
specific proper dosing of many medications
difficult. A  medication error has more
opportunity of occurring in infants and
children. There has been considerable
research on the extent and nature of
medication errors in pediatric patients.[3]
Medication errors, broadly defined as
any error in the prescribing, dispensing
of whether such errors lead to adverse
consequences or not, are the single most
preventable cause of patient harm.[4]
A medication error can occur at any step of
the medication use process. Some adverse
drug events  (ADEs) are associated with
medication errors and all potential ADEs
are medication errors.[5]
In a hospital, all the drugs a patient is
given is under the control of the physician
and patient compliance especially in the
pediatric age group can be ensured to
maximum.
Nevertheless, errors may occur and wrong
drug or dose is given to the patient. In
infants and children, a greater magnitude
of errors is likely to occur because of small
body size and calculation of doses on the
basis of weight. Despite correct diagnosis,
such errors may result in treatment failure
and complications in seriously ill‑children.[6]
Medication Errors
The goal of drug therapy is the achievement
of defined therapeutic outcomes that improve
a patient’s quality‑of‑life while minimizing
patient risk.[7] There are inherent risks, both
known and unknown, associated with the
therapeutic use of drugs (prescription and
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Hugar, et al.: Medication errors
non‑prescription) and drug administration devices. The
incidents or hazards that result from such risk have been
defined as drug mis‑adventuring, which includes both
adverse drug reactions and medication errors.[8]
A more recent definition of medication error as ‘a failure
in the treatment process that leads to, or has the potential
to lead to, harm to the patient’ has recently been proposed,
along with a psychological approach to the classification of
medication errors according to whether they are mistakes,
slips or lapses.[4]
Such events may be related to the professional practice,
health‑care products, procedures and systems, including
prescribing, order communication, product labeling,
packaging and nomenclature compounding, dispensing
distribution, administration, education, monitoring and use.[9]
Incidence
Incident rates of medication errors vary widely, the reason
for which can be explained by the different study methods
and definitions used. The rate of medication errors varies
between 2% and 14% of patients admitted to hospital, with
1‑2% of patients in the United States being harmed as a
result and the majorities are due to poor prescribing. The
incidence is likely to be similar in the United Kingdom.
Medication errors (7% of all incidents) were the second
most common incident reported (after patient falls) in a
recent National Audit Commission report on patient safety.[4]
Classification of Medication Errors
A classification system based on a psychological approach
has been proposed, which allows one to identify broad
categories of error, quantify them and develop an
intervention to prevent them. This classification system[10]
divides errors into mistakes, slips or lapses.
• Errors – when actions are intended but not performed
• Mistakes – errors in planning actions
• Knowledge‑based errors
• Rule‑based errors
• Bad rules or failure to apply good rules
• Good rules misapplied
• Skill‑based errors (slips and lapses) – errors in executing
correctly planned actions
• Action‑based errors (slips)
• Memory‑based errors (lapsed).
Technical Errors
Mistakes may be defined as errors in the planning of an
action and may be knowledge‑based (e.g., giving a medication
28
without having established whether the patient is allergic
to that medication) or rule‑based. Rule‑based errors can
further be classified as either the misapplication of a good
rule  (e.g.,  injecting a medication into the non‑preferred
site) or the application of a bad rule or failure to apply a
good rule (e.g., using excessive doses of a drug). Slips and
lapses are errors in the performance of an action – a slip
through an erroneous performance (e.g., writing the more
familiar “chlorpropamide” instead of “chlorpromazine”)
and a lapse through an erroneous memory (giving a drug
that a patient is already known to be allergic to). Technical
errors are the result of a failure of a particular skill (e.g., in
the insertion of a cannula) and are therefore a subset of
slips (skill‑based errors).
Other way of classifying medication error can be according
to its type and stage of error.[11]
Error type
Errors in dose, frequency, route, medication administration
record transcription or documentation, wrong drug, wrong
patient, known allergy, illegible order, missing or wrong
weight and no date or wrong date.
Stage of error
Physician ordering, transcribing, nurse administering,
pharmacy dispensing, patient monitoring, missing.
Following are the common types of errors encountered
in practice.[12,13]
Prescribing error
Incorrect dr ug selection  (based on indications,
contraindications, known allergies, existing drug therapy
and other factors), dose, dosage form, quantity, route,
concentration, rate of administration or instructions
for use of a drug product ordered or authorized by
the physician  (or other legitimate prescriber); illegible
prescriptions or medication orders that lead to errors that
reach the patient.
Improper dose error
Administration to the patient of a dose that is greater
than or less than the amount ordered by the prescriber or
administration of duplicate doses to the patient, i.e. one or
more dosage units in addition to those that were ordered.
Wrong dosage‑form error
Administration to the patient of a drug product in a
different dosage form than ordered by the prescriber.
Wrong drug‑preparation error
Drug product incorrectly formulated or manipulated
before administration.
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Hugar, et al.: Medication errors
Wrong administration‑technique error
Inappropriate procedure or improper technique in the
administration of a drug.
Deteriorated drug error
Administration of a drug that has expired or for which
the physical or chemical dosage‑form integrity has been
compromised.
Omission error
The failure to administer an ordered dose to a patient
before the next scheduled dose, if any.
Wrong time error
Administration of medication outside a predefined time
interval from its scheduled administration time (this interval
should be established by each individual health‑care facility).
Unauthorized drug error
Administration to the patient of medication not authorized
by a legitimate prescriber for the patient.
Compliance error
Inappropriate patient behavior regarding adherence to a
prescribed medication regimen.
Monitoring error
Failure to review a prescribed regimen for appropriateness
and detection of problems or failure to use appropriate
clinical or laboratory data for adequate assessment of
patient response to prescribed therapy.
Other medication error
Any medication error that does not fall into one of above
predefined categories.
Among these errors, prescribing errors accounted for
more than 10% of all errors detected. The risk of such
prescribing errors is compounded by the substantial
deficiency in the understanding of medication dosage
formulation issues by many health‑care professionals.[14‑17]
Implication of Medication Errors
Medication errors compromise patient confidence in
the health‑care system and increase health‑care costs.
The problems and sources of medication errors are
multidisciplinary and multi‑factorial. Errors occur from
lack of knowledge, substandard performance and mental
lapses or defects or failures in the system.[3,18] The incidence
of medication errors is indeterminate; valid comparisons
of different studies on medication errors are extremely
difficult because of differences in variables, measurements,
populations and methods. Many medication errors
Indian Journal of Oral Sciences  Vol. 5  Issue 1  Jan-Apr 2014
are probably undetected. The outcome(s) or clinical
significance of many medications errors may be minimal,
with few or no consequences that adversely affect a patient.
Tragically, however, some medication errors result in
serious patient morbidity or mortality.
Thus, medication errors must not be taken lightly and
effective systems for ordering, dispensing and administering
medications should be established with safeguards to
prevent the occurrence of errors. These systems should
involve adequately trained and supervised personnel,
adequate communications, reasonable workloads, effective
drug handling systems, multiple procedural and final
product checks by separate individuals, quality management
and adequate facilities, equipment and supplies.
Monitoring medication errors
Ongoing quality improvement programs for monitoring
medication errors are needed.
Hartwig, Denger and Schneider defined seven medication
error severity levels as follows:
Level 0: Non‑medication error occurred (potential errors
would be classified here)
Level 1: An error occurred that did not result in patient
harm
Level 2: An error occurred that resulted in the need for
increased patient monitoring but no change in
vital signs and no patient harm
Level 3: An error occurred that resulted in the need for
increased patient monitoring with a change in vital
signs, but no ultimate patient harm or any error
that resulted in the need for increased laboratory
monitoring
Level 4: An error occurred that resulted in the need for
treatment with another drug or an increased
length of stay or that affected patient participation
in an investigational drug study A
Level 5: An error occurred that resulted in permanent
patient harm
Level 6: An error occurred that resulted in patient death.[19]
Implication in Pediatric Dentistry
As there is a greater variation in the individual dose
requirement in every patients including pediatric patients
when weight can vary from  <1  kg to  >70  kg, the
formulation of many medicines is appropriate for adults,
but not for pediatric patients, therefore making age specific
proper dosing of many medications difficult. Given
these circumstances (i.e. lack of prescribing information,
individualized dosing and inappropriate formulations), a
medication error has more opportunity of occurring in
infants and children.
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Hugar, et al.: Medication errors

The most frequent type of medication error reported Table 1: Formulas for calculation of pediatric doses
in pediatric practice was incorrect dose of the drug and Rules Description
administration of the wrong drug was the second most Weight of child in pounds × adult dose
Clarks’ rule
common type of medication error.[12] Pediatric patients 150
experience unique differences from the adult population Young’s formula
Age in years
× adult dose
in pharmacokinetic parameters and consequently, require Age + 12
individualized dosing. Fried’s formula
Age in months × adult dose
150
Salisbury formula Children weighing less than 30 kg:
Medications useful in pediatrics often lack a therapeutic weight×2=% of the adult dosage
indication and dosing guideline for this population. In Children weighing more than 30 kg:
addition, the absence of an available pediatric dosage weight+30=% of the adult dosage
form for some medications increases the potential for Body surface Pediatric dosage=BSA of the child×adult
area (BSA) dosage 1,73 m2
dosing errors and may produce serious; sometimes fatal
Penna’s formula Adult dose×Child’s weight÷Child’s
complications in young patients. It is important to select an weight/2+30
appropriate medication and dose based on individualized Age in years × adult dose
pharmacokinetic considerations: one must evaluate a Dilling’s formula
20
patient’s age, size and level of organ maturity and not Age at next birthday
Cowling’s rule × adult dose
simply administer a “small adult” dose. Thus, specific dosing 24
guidelines and useful dosage forms for pediatric patients Age + 3
need to be developed in order to optimize therapeutic Bastedo’s rule × adult dose
30
efficacy and limit or prevent serious adverse side‑effects.[20] wt.pd
Ander’s rule Dose (p) = Dose (a) ×
wt.ad
The various dosing guidelines for pediatric patients are Mg/Kg regimen Multiply the means and the extremes (e.g.,
Ratio–proportion 3:4 = X: 8)
listed in Table 1. method D/H × Q = X
Formula method D = Dosage desired or ordered
Prevention H = What is on hand (available)
Q = Unit of measure that contains the
available dose
A medication error is any preventable event occurring X = The unknown dosage you need to
in the medication‑use process, including prescribing, administer
transcribing, dispensing, using and monitoring that results
in inappropriate medication use or patient harm. These to treat or prevent illness. Through a systems‑oriented
errors and their consequences present a significant public approach, the pharmacist should lead collaborative,
health threat to Californians. Although most consumers multidisciplinary efforts to prevent, detect and resolve
and health‑care providers do not often associate poor drug‑related problems that can result in patient harm.[7]
health outcomes with ADE  –  frequently the result of
medication errors – the human and financial costs of the Many medication errors are probably undetected. The
problem are staggering. outcome(s) or clinical significance of many medication errors
may be minimal, with few or no consequences that adversely
Medication errors compromise patient confidence in
affect a patient. Tragically, however, some medication errors
the health‑care system and increase health‑care costs.
result in serious patient morbidity or mortality.
The problems and sources of medication errors are
multidisciplinary and multifactorial. Errors occur from
Thus, medication errors must not be taken lightly and
lack of knowledge, substandard performance and mental
effective systems for ordering, dispensing and administering
lapses, or defects or failures in systems. Medication
errors may be committed by both experienced and medications should be established with safeguards to
inexperienced staff, including pharmacists, physicians, prevent the occurrence of errors.[12]
nurses, supportive personnel (e.g., pharmacy technicians),
students, clerical staff  (e.g., ward clerks), administrators, Computerized Physician Order Entry
pharmaceutical manufacturers, patients and their
caregivers and others.[21] CPOE is an application in which physicians write orders
online. This system has probably had the largest impact of
Perhaps the most concerning aspect of these errors is that any automated intervention in reducing medication errors;
the tremendous human and financial costs are not the result computerization of ordering improves safety in several
of some serious disease, but rather, well‑intentioned attempts ways: firstly, all orders are structured, so that they must

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Hugar, et al.: Medication errors
include a dose, route and frequency; secondly, they are
legible and the orderer can be identified in all instances;
thirdly, information can be provided to the orderer during
the process; and fourthly, all orders can be checked for a
number of problems including allergies, drug interactions,
overly high doses, drug laboratory problems.
The complexity of health‑care and the rate of medical
errors has led to the use of information technology to
improve safety.[22]
CPOE systems have been widely recognized as an
important technology for preventing ADE, a common
type of error.[23,24]
Medication errors are preventable through physician
computer order entry. It can prevent non‑missing dose
medication errors, potential ADEs and preventable ADEs.[25]
The effect of CPOE implementation in a pediatric
population has also been reported.
The development of CPOE systems that are adaptable to
pediatric critical care environments has been problematic.
Developing systems that provide weight‑based dosing as
well as age‑specific algorithms, is difficult and applicable
only to a small proportion of the overall health‑care
market. There are limited data on the impact of CPOE
on medication errors in pediatric patients.[26]
Conclusion
All health‑care professionals have a responsibility in
identifying contributing factors to medication errors
and to use that information to further reduce their
occurrence. A  multidisciplinary approach to solving
the problem of medication errors needs to be taken.
Medication errors are one of the most preventable
causes of patient injury although the incidence of such
errors varies widely as a result of differing definitions
and methodologies.
Recommendation for the prescribers
• Medication use systems can be made safe by making
them resistant to error and by adding important checks
and controls
• Selection and use of appropriate dosing formula
• The provision of appropriate medicines for pediatric
patients. A leading zero should always precede decimal
expressions less than one (0.1 mg) but, a trailing zero
should never follow a whole number (1. 0 mg) (i.e. do
not enable 10‑fold errors or 100‑fold errors)
• Drug orders should be legible and should contain all
the components of the prescription
Indian Journal of Oral Sciences  Vol. 5  Issue 1  Jan-Apr 2014
• If the doses have to be changed, new prescription
should be written. Old ones are cancelled
• Patient should be instructed to shake a drug product
that is labeled “Shake well”
• The aim must be to drastically reduce medication errors
in all patients and in particular, in infants, children and
adolescents.
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