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Ghaleb MA, Barber N, Franklin BD, Wong ICK
Department of Practice and Policy and Centre of Paediatric Pharmacy Research, School of Pharmacy, University of London, 29-39 Brunswick Square, London WC1N 1AX

Medication errors are not uncommon in paediatrics, particularly dosing errors1. There is no drug chart/case note review study of paediatric prescribing errors in the UK, all studies focused on analysis of incident reports. 

To establish the feasibility of a multi-centre study investigating the incidence and nature of paediatric prescribing errors.

A review of the drug charts was undertaken for 2 weeks by the senior pharmacist for each of the paediatric intensive care unit (PICU), surgical, and medical wards at a large paediatric hospital. The researcher accompanied the senior pharmacists during their visits to these wards and recorded any prescribing errors identified. The pharmacists were given a list of events that might trigger an investigation into whether a prescribing error had occurred.

The pharmacists for all three wards reviewed a total of 1066 medication orders. Various types of prescribing errors were identified. In the surgical, medical and PICU wards, 58, 34 and 70 errors were identified respectively; 51% of these errors involved the use of abbreviations. If these were excluded, the most common types were illegibility and incomplete prescriptions. The latter included not indicating the dose, route, frequency and duration of the drug, and not signing the prescription. Dosing errors were the second most frequent type and accounted for 5 (31%) and 2 (15%) of the errors in the surgical and medical wards respectively, and 6 (12%) of the errors in the PICU. There was one tenfold error in the PICU involving phenytoin, of which the first dose was given to the patient but no harm resulted. The prescribing error rates in the surgical, medical and PICU wards were 7.9, 8.0, and 7.6 per 100 medication orders respectively. The dosing error rates were 2.5, 1.2 and 0.9 per 100 medication orders in the surgical, medical and PICU wards respectively. 

The results demonstrate that this data collection method is feasible, and can be used in a multi-centre study of prescribing errors in paediatrics. Various types of prescribing errors were identified, and their incidences were greater than those reported in similar studies in the USA2-3, which ranged from 0.47 – 2.7 per 100 medication orders. There is a need to reduce medication errors in children, particularly dosing errors.


  1. Wong IC, Ghaleb MA, Franklin BD, et al. Incidence and nature of dosing errors in paediatric medications. Drug Saf 2004; 27(9): 661-670.

  2. Blum KV, Abel SR, Urbanski CJ, et al. Medication error prevention by pharmacists. Am J Health Sys Pharm 1988; 45(9): 1902-1903.

  3. Folli HL, Poole RL, Benitz WE, et al. Medication errors prevention by clinical pharmacists in two children's hospitals. Pediatrics 1987; 79(5): 718-722

Presented at the HSRPP Conference 2005, Reading