Evidence of frequent dosing errors in paediatrics and intervention to reduce such prescribing errors R. Bolt* BDS (Hons) MFDS MBChB (Hons) MClinRes, J. M. Yates† BSc (Hons) BDS PhD MFDSRCPS FDSRCPS, J. Mahon‡ BDS and I. Bakri§ BDS, MFDS, PhD *Department of Oral Surgery,School of Clinical Dentistry, University of Sheffield, Sheffield, †Oral and Maxillofacial Surgery, School of Dentistry, University of Manchester, Manchester, ‡Oral and Maxillofacial Surgery, Sheffield Teaching Hospitals NHS Trust, Sheffield, and §Department of Oral Surgery, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK Received 20 November 2011, Accepted 31 October 2013 Keywords: accuracy, anaesthetics, oral maxillofacial surgery, prescribing, prescription, variability SUMMARY What is known and objective: Drug prescribing is an essential part of inpatient care, and prescription errors/omissions have the potential to lead to disastrous consequences. Paediatric inpatient prescribing is particularly sensitive to error due to the weight- adjusted dosing of many medications prescribed in the acute setting. Previous studies have described a high incidence of error in adult drug chart completion, although no studies to date have assessed the error seen in the paediatric setting or accuracy of weight-adjusted dosing. Our objective was to determine the degree of error seen in paediatric drug prescribing for patients admitted under the care of oral and maxillofacial surgery and to explore practical and accessible methods through which error can be reduced. Methods: We retrospectively evaluated inpatient drug charts to assess the prescribing practices seen for patients admitted under the care of oral and maxillofacial surgery in an NHS children’s hospital and compared these findings against established hos- pital standards. The study also examined the distribution and variability of weight-adjusted dose prescribing in an attempt to set targets for auditing improvements following the implemen- tation of changes. Results and discussion: Prescriptions were completed by a combination of doctors from maxillofacial and anaesthetic teams, with similar error rates seen in both specialties. 13% of drug charts contained one or more errors in frequency prescrib- ing. For weight-adjusted drugs, a median under-dosage of À5Á4% was noted, with an IQR of À12 to À0Á6. Our study has confirmed that errors are common both in the manual comple- tion of paediatric prescription charts and in the calculation of weight-adjusted doses. What is new and conclusion: We conclude that inaccuracies in prescription chart completion are a frequent occurrence and that dosage and frequency-prescribing errors may potentially act synergistically to create a significant disparity between the recommended and actual amount of drug that is delivered. Our study demonstrates a clear bias towards under-prescribing weight-adjusted doses which may be contributing to reduced efficacy of analgesia, among other drugs. Simple methods can be implemented on a specialty basis to improve the accuracy of both drug chart completion and weight-adjusted dosing. WHAT IS KNOWN AND OBJECTIVE The clinical approach to paediatric drug prescribing differs greatly to that practised in the adult setting, whereby drugs are often prescribed either at a generic dose or titrated up to a ‘maximum allowed dose’ irrespective of patient weight. As a consequence, prescribing for adults in the majority of cases is relatively straightforward, with most clinicians having a detailed working knowledge of the dose and frequency of common medications. In contrast, paediatric dose requirements are less predictable; a child’s size may not reflect their chronological age and conse- quently generic dosages may be inappropriate. Furthermore, a child may be developmentally delayed or have failure to thrive and may therefore be unable to safely absorb, metabolize or excrete the same quantity of drug appropriate to a normally developed counterpart. 1 Paediatric dosing must therefore take into account a child’s ability to metabolize and excrete the prescribed drug. This may be achieved using a weight model, 1 which may go some way in helping to predict an individual’s potential for drug absorption, distribution, metabolism and subsequent clearance. The British National Formulary (BNF) for Children lists the weight-adjusted doses of various drugs commonly prescribed in all branches of medicine and surgery and therefore acts as an invaluable tool for ensuring the safe and appropriate prescribing of medication. 2 However, there is common practice to halve or quarter an adult dose of oral medications based on a child’s age, and this practice may act as a shortcut for estimating drug doses that require weight adjustment, leading to the delivery of medication at a level that is often adequate but not optimized, and on occasion inappropriate. Under-dosing of certain drugs may result in failure to achieve therapeutic concentration within the plasma or targeted body compartment. Delivery of an antibiotic below its minimum inhibitory concentration (MIC) will have little influence on infective processes and, with prolonged exposure, may promote selection for bacterial resistance. Furthermore, inadequate dosing of simple analgesia may lead to supplementation with additional analgesics that have less-desirable side effect profiles, such as opioids, 3 whereas a maximized dose of the initial analgesic may have sufficed. 4 The objectives of this investigation were to analyse the extent of weight-adjusted prescribing error in children admitted under the Correspondence: Robert Bolt, Oral Surgery Unit, The University of Sheffield, School of Clinical Dentistry, 19 Claremont Crescent, Sheffield, S10 2TA, UK. Tel.: 00 44 (0)114 2265463; fax: 0114 271 7863; e-mail: r.bolt@sheffield.ac.uk © 2013 John Wiley & Sons Ltd 78 Journal of Clinical Pharmacy and Therapeutics, 2014, 39, 78–83 doi: 10.1111/jcpt.12114