What is the 10-fold dosage error?

The 10-fold dosage error applies to medication errors when the dosage is 10 times higher or lower than appropriate. This significant error accounts for as much as 4.5% of medication-related safety errors in children, Canadian researchers found. 

Due to their wide ranges in age, body size, and more, children are at risk for significant “tenfold” dosing errors. These problems also occur due to variation in formulations and dilutions frequently used with children-patients, the researchers found. 

The investigators are anesthesiologists at the Hospital for Sick Children in Toronto, Catherine Doherty, MD, and Conor McDonnell, MD. As part of their work, they included suggestions for hospitals to implement to prevent tenfold errors, and other errors, in pediatric units. These recommendations included 1) vigilance for specific drug use; 2) pharmacotherapy clinical care bundles for sepsis in the emergency room, pediatric intensive care unit (PICU) and neonatal intensive care unit (NICU); 3) opioid ordering and dispensing; and 4) the development of new drug delivery systems and IV pumps. 

“Intravenous pumps need to be redesigned and re-imagined while taking human factors engineering and safety practices into account. Many pediatric tenfold errors could be avoided if the design of the keypad did not have the ‘decimal point,’ ‘zero’ and ‘confirm’ buttons side by side,” Dr. McDonnell told Anesthesiology News. 

To identify the scope of the problem, the researchers relied on data collected from 300 pediatric care centers. This information was submitted voluntarily by the clinics as part of their medication-related safety reports. The reports included data on how frequently errors were reported, the type of pharmacy error involved, the frequency of a particular error, drugs and drug classes involved in the error, and the extent of patient harm. 

6,000 reports were submitted in the 2000s, which came to 2-3 reports per day during the five years of the study. Of those 6,000 reports, 252 were 10-fold medication errors. 178 involved overdoses and 74 were under doses. Unfortunately, opioids were the drug class most frequently cited in a tenfold error, and morphine was the most commonly involved drug. Patient harm was reported in 22 cases, which is more than anyone wants. 

Errors frequently resulted from math mistakes such as incorrect dosage calculations, documentation of decimal points, and the addition of extra zeros. Tenfold errors occurred most often in the PICU and NICU. Errors that led to harm were most likely to take place on the hospital wards. 

The study was presented at the 2011 annual meeting of the Canadian Anesthesiologists’ Society (abstract 1066898).