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Publication Type: Medical Safety Information
Single or Multiple Incident: Multiple
Date: 4/1/2009 12:00:00 AM
Country: Japan

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.

Additional Details

Medication/Gas/Fluid:
multivitamin with iron (Incremin®), digoxin (Digosin®), dexamethasone (Decadron®), mitoxantrone (Novantron®), dalteparin (Fragmin®), flomoxef (Flumarin®), clobazam (Mystan®), warfarin
Medication/IV List:
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