@article{1129, keywords = {acetaminophen, medication error, poison prevention, regional poison control center}, author = {Eric P. Brass and Kate M. Reynolds and Randy I. Burnham and Jody L. Green}, title = {Medication Errors With Pediatric Liquid Acetaminophen After Standardization of Concentration and Packaging Improvements.}, abstract = {

OBJECTIVE: To assess the impact of the 2011 changes in pediatric single-ingredient liquid acetaminophen product packaging and standardization of the acetaminophen concentration (160 mg/5 mL) on poison control center exposures due to medication errors.

METHODS: National Poison Data System (NPDS) data from January 1, 2007, through December 31, 2016, were used to identify medication error exposures involving single-ingredient liquid acetaminophen in children younger than 12 years of age. Surveys were conducted through 6 regional poison control centers to obtain additional information on a subset of exposures.

RESULTS: The annual frequency of NPDS exposures due to medication errors with single-ingredient liquid acetaminophen products was 8260 ± 670 exposures/year during 2007-2011. Children <2 years of age accounted for 66% of exposures. The overall rate of exposures fell to 6669 ± 662 during 2012-2016 (19% decrease; P = .005). Four percent of exposures led to health care facility referrals. Caregivers involved with exposures in children <2 years of age cited health professionals as the source of dosing information in only 69% of cases despite the absence of specific dosing directions for these children on product labels.

CONCLUSIONS: Implementation of a single concentration for pediatric liquid acetaminophen products and packaging changes were associated with a decrease in medication errors reported to poison control centers. Medication errors are particularly problematic for children <2 years of age, for whom there are no specific labeled dosing instructions. Improved efforts to provide caregivers with dosing instructions for these children are encouraged.

}, year = {2018}, journal = {Acad Pediatr}, volume = {18}, pages = {563-568}, month = {12/2018}, issn = {1876-2867}, doi = {10.1016/j.acap.2018.03.001}, language = {eng}, }