Pediatric medication errors, safe medication disposal

One to One

A child receives the wrong medication or incorrect dose every 8 minutes, according to a new retrospective analysis of out-of-hospital medication errors among children. Researchers reported that nearly 700,000 children younger than 6 years experienced an out-of-hospital medication error between 2002 and 2012.

“Pediatric medication errors are a very real and serious public health concern,” said Ray Bullman, Executive Vice President of the National Council on Patient Information and Education (NCPIE). “Pharmacists are uniquely positioned to counsel parents and caregivers about how to read OTC medication labels and determine the correct dose.”

Analgesic errors most common

Analgesics were most commonly involved in medication errors, followed by cough and cold preparations.

Published in the November issue of Pediatrics, the study analyzed data from the National Poison Database System. The researchers reported that nearly 82% of medication errors involved a liquid formulation, followed by tablets, capsules, or caplets. The researchers found that analgesics were most commonly involved in medication errors, followed by cough and cold preparations.

Inadvertently taking or being given medication twice accounted for 27% of medication errors, and ingestion accounted for 96% of events, researchers noted.

“Cough and cold medication errors decreased significantly, whereas the number (42.9% increase) and rate (37.2% increase) of all other medication errors rose significantly,” the researchers wrote. “Increased efforts are needed to prevent medication errors, especially those involving non–cough and cold preparations among young children,” they added.


Acetaminophen dosing

The Acetaminophen Awareness Coalition advises that parents and caregivers use weight to determine the correct dose, followed by age. In 2011, manufacturers changed liquid acetaminophen products for infants, so parents and caregivers should always check the concentration of acetaminophen medications. Prior to 2011, liquid acetaminophen products for infants were a different concentration than liquid acetaminophen for older children, according to the coalition’s website, After 2011, the acetaminophen products are the same concentration. According to the coalition, the new acetaminophen concentration is 160 mg/5mL, which should be listed on the front of the medicine bottle.

The coalition suggests that parents and caregivers use the oral syringe or plastic cup that comes with the product in order to measure the correct dose. The group reminds parents and caregivers to keep acetaminophen and all medications out of sight to prevent accidental ingestion. A downloadable chart to help parents identify the correct dose of acetaminophen can be found at

Medication disposal

FDA and the White House Office of National Drug Control Policy released a consumer update that lists several guidelines for the safe disposal of unused prescription and OTC medications. The group advises patients not to flush medications down the toilet and to follow disposal instructions if they accompany the medication. Patients should use community drug take-back programs that allow the public to bring unused drugs to a central location for proper disposal.

As a final option, the group recommends putting the medications in the household garbage by removing the packaging and mixing them with an undesirable substance such as used coffee grounds or kitty litter, and placing the mixture in a sealable bag or container to keep it from leaking.

“Patients should talk to their pharmacist if they have any questions about where to safely store medications or the best disposal methods,” said Bullman.

For more information on safe medication storage and disposal, NCPIE offers a free downloadable resource online.