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Clinical Pediatrics

49(1) 49­–53
Prescribing Errors in a Pediatric Clinic © The Author(s) 2010
Reprints and permission: http://www.
DOI: 10.1177/0009922809342459

Michelle Condren, PharmD,1 I. John Studebaker, MD,2 and

Barnabas M. John, PharmD3

Objective: This project was completed to determine the frequency and type of prescribing errors occuring in a pediatric
clinic. Study design: Records for all patient encounters in the pediatric acute care clinic from February through April
2007 were reviewed. Prescriptions entered into the electronic medical records (EMR) were reviewed the day after
they were written. Results: A total of 3523 records containing 1802 new prescriptions were reviewed. Prescribing
errors were found in 175 prescriptions (9.7%). The most common type of error was an incomplete prescription (42%),
followed by dosing errors (34%). Anti-infectives were most commonly written in error followed by anti-inflammatories.
Conclusions: Prescribing errors were commonly identified in a pediatric clinic utilizing electronic medical records.
Incomplete prescriptions and dosing errors were the most commonly occurring errors. Recognizing the types of errors
has been beneficial for developing educational programs intended to decrease prescribing errors and recommending
improvements to the EMR system and its utilization.

electronic medical record, errors, medication errors, prescription

Medication errors are a dangerous and expensive problem Detection and tracking of prescribing errors is difficult
in healthcare. Whereas the majority of medical care for in the outpatient setting. If the error is not detected in the
children occurs in the outpatient setting, few studies address physician’s office, the patient or pharmacist must identify
the error rates of prescribing for this population.1 In one and report the error. The use of an electronic medical
outpatient study of children, it was determined that the rate record (EMR) provides a means to survey prescriptions
of dosing errors for select medications was 15%.2 Studies in for the presence of errors without cumbersome paper chart
family medicine clinics report error rates ranging from 14% reviews. Identification of the types of errors occurring will
to 19%.3,4 In adults, an outpatient prescribing error study help focus training and educational efforts for clinicians as
reported that 7.6% of prescriptions contained an error.5 well as provide feedback to development teams responsi-
There is no study that addresses the overall incidence of ble for changing the EMR forms and functionality. This
errors in outpatient pediatric prescriptions. It is expected article describes our experience with a commercially
that the rate of errors in prescriptions will be higher for chil- available EMR and the discovery of prescribing errors in
dren than for adults, because of the calculations required to a pediatric acute care clinic.
determine appropriate medication dosages.
Electronic prescribing (e-prescribing) systems are felt
to be an important tool in addressing and reducing pre- Methods
scription errors and adverse drug events, and both issues The objective of this study was to determine the type and
have been demonstrated in hospital settings. However, the frequency of prescribing errors that occur in an academic
degree to which e-prescribing has contributed to prescrip- 1
University of Oklahoma College of Pharmacy, Tulsa, OK, USA
tion error reduction has not been well documented in the 2
Department of Pediatrics, University of Oklahoma School of Community
outpatient environment. Much of the benefit of e-prescribing Medicine, Tulsa, OK, USA
systems is based on eliminating clinicians’ handwriting 3
Saint Francis Hospital, Tulsa, OK, USA
interpretation, and this benefit should translate effectively
Corresponding Author:
to the outpatient setting. However, the degree to which an Michelle Condren, University of Oklahoma College of Pharmacy, 4502
e-prescribing system can decrease errors is likely related to E 41st, Tulsa, OK, USA 74135
the amount of decision support it provides the clinician. Email:

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50 Clinical Pediatrics 49(1)

Figure 1. Types of prescribing errors detected.

pediatric clinic. From February 2007 through April Results

2007, a chart review was performed for all patients seen
in the pediatric acute care clinic. Providers for these A total of 3523 charts and 1802 new prescriptions were
visits included faculty physicians, resident physicians, reviewed. Prescribing errors were present in 9.7% of new
and nurse practitioners. Chart reviews by a pharmacist prescriptions. Errors in historical data were found in 4%
and pharmacy students to identify prescribing errors of the charts reviewed. Incomplete prescriptions and
were conducted the day after the patient visited the errors in dosing were the most prevalent error types. The
clinic. All medications entered into the EMR for the most common error subcategory was missing instructions,
patients seen were reviewed for completeness and followed by doses exceeding the recommended dosages.
appropriateness. Figure 1 shows the types of errors detected.
Data collected included the number of charts reviewed, The most common reason for an incomplete prescrip-
number of prescriptions written, number of prescribing tion was missing instructions, followed by a quantity
errors, medication involved in the error, and type of error. determination of quantity sufficient without providing a
Data were also collected on medications that had been day’s supply. Anti-infectives accounted for 55% of the
entered into the patients’ charts prior to that day’s visit and prescribing errors. Figure 2 summarizes the types of med-
were recorded as errors in historical data entry. Prescribing ications involved in prescribing errors. Table 1 provides
errors were categorized into 5 broad categories: inade- an overall summary of the types of errors detected. There
quate prescription, dosing outside the recommended was no significant difference in the percentage of pre-
range, drug selection error, documentation error, and scriptions containing errors for prescriptions written in
administration error, each with subcategories. When February, March, and April.
determining if a medication dose was above or below the
recommended one, a 10% margin of error was allowed.
When an error occurred, the provider was notified, and the Discussion
error was corrected at the patient and pharmacy levels This study shows that errors in prescribing occurred in
when possible. Data were summarized using Microsoft almost 10% of new prescriptions written for children pre-
Office Excel. senting at an acute care clinic. More specifically, errors in

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Condren et al 51

Figure 2.  Medications involved in prescribing errors.

dosing occurred in 6% of prescriptions written, often exceed- contained an error, but this study included medication
ing the recommended dose. Many of the errors caused by administration errors by the ED staff.7 Only 14% of the
incomplete prescriptions did not place the patient in any orders contained an error, similar to the current study.
immediate danger but would be expected to delay receipt A second study involving a pediatric ED found that 59%
of the medication, and therefore treatment, by the patient of the prescriptions written by residents contained an
while the pharmacy awaited clarification of the order. error, with omitted information being the most common
Because of the study design, it is unknown if the errors that error.8 The majority of the reported errors in this study
occurred resulted in untoward clinical outcomes. arose from failure to include a number of refills on the
There is little data reported describing prescribing prescription. Dosing errors were detected in 6% of pre-
errors for outpatient pediatrics. In a study of pharmacy scriptions, results that parallel the current study. A third
data from health maintenance organizations, dosing errors study was performed to determine if making changes to a
were evaluated and found to occur in 15% of the prescrip- physician order entry system would decrease errors.9 That
tions dispensed for children.2 Although this is higher than study reported an error rate of 31 per 100 orders before
our reported rate of 6%, the prior study only evaluated system modifications and 14 per 100 orders after deploy-
overdose errors for specific medications, thus, limiting the ment of the system changes.
types of prescriptions evaluated. In a study of prescribing Studies have commented on the role of computerized
and administration errors for oral outpatient chemother- order entry in contributing to medication errors. A study of
apy for children, prescribing errors were only found in 3% pediatric inpatient orders showed that 19% of errors could
of the prescriptions written.6 This population of patients be attributed to computer use. It identified the computer-
received a limited number of medications compared with related errors as duplicate orders, selecting the wrong
our study population. medication out of a drop-down menu, errors in keypad
Studies including a review of prescriptions written for entry, and using an inappropriate order set for the patient.10
children in the emergency department (ED) report higher A second study of inpatient orders for adults reported
rates of prescribing errors overall. A study evaluating that 22 sources of medication errors were facilitated by
errors in a rural ED reported that 39% of prescriptions computerized physician order entry.11

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52 Clinical Pediatrics 49(1)

Table 1.  Summary of Errors Detected incorporated into resident training and monthly clinic ori-
entation. Modifications to the EMR application have been
Total (Percentage
Type of Error of Total Errors) made to provide dosing guidance for certain medications
and to limit the number of medications and dosage forms
Incomplete/inadequate RX 138 (43) that can be selected for patients. The dosing calculator
Directions missing 59 (18.4) errors have been corrected by the EMR vendor.
Quantity sufficient (QS) 39 (12)
A limitation of this study is that it did not count the total
  with no days supply
Directions unclear 14 (4.4) number of prescriptions written for specific medications
Strength missing 10 (3) to determine the frequency with which errors occurred for
Quantity calculated in error 9 (2.8) an individual product. Therefore, it is possible that the
Quantity missing 4 (1.3) prescription errors occurred most often for anti-infectives
Frequency missing 3 (1) because they composed the majority of prescriptions writ-
Dosing outside recommended 112 (35) ten. This study did not sort error frequency by provider
Exceeds recommended dose 49 (15.3)
type or by patient demographics. Such data would be
Below recommended dose 32 (10)
Frequency outside recommended 15 (4.7) helpful for further improving educational programs or
Outside range for indication 11 (3.4) targeting medication review efforts.
Duration outside recommended 5 (1.6) One problem encountered when attempting to resolve
Drug selection errors 45 (14) errors was that some families could not be reached to
Wrong dosage form 16 (5) discuss needed changes to the prescriptions. A thorough
Direction/dosage form mismatch 12 (3.7) prescription review before the prescription leaves the clinic
Dosage form not available 9 (2.8)
would increase patient safety by ensuring that an improper
Not recommended for age 5 (1.6)
Patient allergic to medication 2 (0.6) medication or dosage would not reach the patient.
Wrong drug selected from list 1 (0.3) Although the EMR system has brought many advan-
Documentation error 22 (6.9) tages to the management of medications, the study has
Patient taking but not in medication list 15 (4.7) highlighted some high-level deficiencies of the system.
Wrong weight 4 (1.25) Our EMR vendor purchases its medication content from a
Allergy not documented 3 (1) third-party company, a common practice for EMR sys-
Administration error 4 (1.25)
tems. This relationship has handicapped the EMR system’s
Technique not recommended 3 (1)
Immeasurable dose 1 (0.3) ability to rapidly evolve to meet the medication manage-
ment needs of outpatient clinics. Simple changes such as
the ability to highlight the difference between an oral solu-
This study prompted our institution to investigate tion and an intravenous solution have not been
reasons for errors. We identified not only human errors implemented. As this study illustrates, errors in prescrib-
in math and reference use but also errors with the EMR ing can and do happen as a result.
system used by the providers. The clinic’s EMR system
has no decision support to prevent ordering inappropriate
dosages of medications. There is no forced completion of Conclusions
fields, allowing the quantity, frequency, and instruction Prescribing errors are common in an academic pediatric
fields to remain blank. We discovered errors in calcula- clinic using EMRs. Incomplete prescriptions and dosing
tions made by the internal dosing calculator leading to errors were the most commonly identified errors. Identify-
overdose errors. The data also identified EMR training ing the types, frequency, and cause of errors is beneficial
for providers that would be needed to decrease medica- for developing focused educational programs intended to
tion errors. decrease prescribing errors. This information also increased
In response to this study, multiple efforts have been the awareness that improvements to EMR systems and
undertaken to improve the system, the providers’ use of their use need to be explored.
the system, and the overall ability to write prescriptions.
Through conducting the study, we have been able to iden- References
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