4/1/2009 12:00:00 AM
This alert discusses eight patient safety incidents where a 10 fold overdose was administered to pediatric patients; several incidents involved high alert drugs. In one incident, digoxin (Digosin®) 0.03 mg was intended for a 3 month old patient. "0.3mg" instead of "0.03 mg," was entered into the computer by the prescriber. The excessive dose was not recognized by pharmacy and the 0.3 mg dose was prepared and subsequently administered.
multivitamin with iron (Incremin®),
antithrombotic agents (anticoagulants),
chemotherapeutic agents, parenteral and oral
inotropic medications, IV (e.g., digoxin, milrinone),
moderate sedation agents, oral, for children (e.g., chloral hydrate)
Administration of 10 times proper dosage to pediatric patients