PEDIATRIC PRESCRIPTIONS - USE CAUTION!!

Each year the Texas State Board of Pharmacy (TSBP) receives complaints alleging that errors occurred in the dispensing of prescriptions. During FY2004, TSBP instituted disciplinary action in 55 cases where a dispensing error was made on a prescription for a pediatric patient or 44% of errors resulting in disciplinary action involved pediatric prescriptions. The chart below reflects the percentage of alleged errors involving pediatric prescriptions for the last five years.
 

	Total # of Disciplinary Orders	Total # of Disciplinary Orders Involving Alleged Dispensing Errors	Total # of Alleged Errors	% of Alleged Errors Involving Pediatric Prescriptions
FY2000	126	43	71	25%
FY2001	145	22	36	31%
FY2002	181	38	45	13%
FY2003	213	82	85	44%
FY2004	235*	101	126	44%

* This number does not include disciplinary orders entered by the Board during FY2004 on pharmacy technicians. This number only includes disciplinary orders entered on pharmacists and pharmacies.

One of the most common dispensing error complaints received by the Board involves prescriptions in which the prescriber has indicated the dosage to be administered to a pediatric patient as a "cc" or "ml" The error occurs when "cc" or "ml" is misread and data entered incorrectly as TEASPOONFUL rather than "cc" or "ml," resulting in incorrect directions for use. This situation is exacerbated when the prescribed number of dosage units is more than one. Pharmacists need to be familiar with pediatric dosages. In reviewing the patient's medication record, the pharmacist should always check the patient's date of birth. Knowing that the patient in an infant/child would alert the pharmacist that the dosage may be different.

Many of these errors could be detected and thereby prevented if the pharmacist conducts a drug utilization review (DUR). Many pharmacists use computer software programs to assist them with DUR. However, most computer software programs do not include age as one of the variables when conducting DUR. Therefore, TSBP encourages pharmacists to work with their software vendors to develop such programs or to place a "hard stop" in the computer to indicate to the pharmacist that this is a pediatric patient and the pharmacist should double check the dosage and directions.