Clinical Pediatrics

49(1) 49­–53
Prescribing Errors in a Pediatric Clinic © The Author(s) 2010
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DOI: 10.1177/0009922809342459
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Michelle Condren, PharmD,1 I. John Studebaker, MD,2 and

Barnabas M. John, PharmD3

Abstract
Objective: This project was completed to determine the frequency and type of prescribing errors occuring in a pediatric
clinic. Study design: Records for all patient encounters in the pediatric acute care clinic from February through April
2007 were reviewed. Prescriptions entered into the electronic medical records (EMR) were reviewed the day after
they were written. Results: A total of 3523 records containing 1802 new prescriptions were reviewed. Prescribing
errors were found in 175 prescriptions (9.7%). The most common type of error was an incomplete prescription (42%),
followed by dosing errors (34%). Anti-infectives were most commonly written in error followed by anti-inflammatories.
Conclusions: Prescribing errors were commonly identified in a pediatric clinic utilizing electronic medical records.
Incomplete prescriptions and dosing errors were the most commonly occurring errors. Recognizing the types of errors
has been beneficial for developing educational programs intended to decrease prescribing errors and recommending
improvements to the EMR system and its utilization.

Keywords
electronic medical record, errors, medication errors, prescription

Medication errors are a dangerous and expensive problem
in healthcare. Whereas the majority of medical care for
children occurs in the outpatient setting, few studies address
the error rates of prescribing for this population.1 In one
outpatient study of children, it was determined that the rate
of dosing errors for select medications was 15%.2 Studies in
family medicine clinics report error rates ranging from 14%
to 19%.3,4 In adults, an outpatient prescribing error study
reported that 7.6% of prescriptions contained an error.5
There is no study that addresses the overall incidence of
errors in outpatient pediatric prescriptions. It is expected
that the rate of errors in prescriptions will be higher for chil-
dren than for adults, because of the calculations required to
determine appropriate medication dosages.
Electronic prescribing (e-prescribing) systems are felt
to be an important tool in addressing and reducing pre-
scription errors and adverse drug events, and both issues
have been demonstrated in hospital settings. However, the
degree to which e-prescribing has contributed to prescrip-
tion error reduction has not been well documented in the
outpatient environment. Much of the benefit of e-prescribing
systems is based on eliminating clinicians’ handwriting
interpretation, and this benefit should translate effectively
to the outpatient setting. However, the degree to which an
e-prescribing system can decrease errors is likely related to
the amount of decision support it provides the clinician.
Detection and tracking of prescribing errors is difficult
in the outpatient setting. If the error is not detected in the
physician’s office, the patient or pharmacist must identify
and report the error. The use of an electronic medical
record (EMR) provides a means to survey prescriptions
for the presence of errors without cumbersome paper chart
reviews. Identification of the types of errors occurring will
help focus training and educational efforts for clinicians as
well as provide feedback to development teams responsi-
ble for changing the EMR forms and functionality. This
article describes our experience with a commercially
available EMR and the discovery of prescribing errors in
a pediatric acute care clinic.
Methods
The objective of this study was to determine the type and
frequency of prescribing errors that occur in an academic
1
University of Oklahoma College of Pharmacy, Tulsa, OK, USA
2
Department of Pediatrics, University of Oklahoma School of Community
Medicine, Tulsa, OK, USA
3
Saint Francis Hospital, Tulsa, OK, USA
Corresponding Author:
Michelle Condren, University of Oklahoma College of Pharmacy, 4502
E 41st, Tulsa, OK, USA 74135
Email: michelle-condren@ouhsc.edu

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50 Clinical Pediatrics 49(1)
Figure 1. Types of prescribing errors detected.
pediatric clinic. From February 2007 through April
2007, a chart review was performed for all patients seen
in the pediatric acute care clinic. Providers for these
visits included faculty physicians, resident physicians,
and nurse practitioners. Chart reviews by a pharmacist
and pharmacy students to identify prescribing errors
were conducted the day after the patient visited the
clinic. All medications entered into the EMR for the
patients seen were reviewed for completeness and
appropriateness.
Data collected included the number of charts reviewed,
number of prescriptions written, number of prescribing
errors, medication involved in the error, and type of error.
Data were also collected on medications that had been
entered into the patients’ charts prior to that day’s visit and
were recorded as errors in historical data entry. Prescribing
errors were categorized into 5 broad categories: inade-
quate prescription, dosing outside the recommended
range, drug selection error, documentation error, and
administration error, each with subcategories. When
determining if a medication dose was above or below the
recommended one, a 10% margin of error was allowed.
When an error occurred, the provider was notified, and the
error was corrected at the patient and pharmacy levels
when possible. Data were summarized using Microsoft
Office Excel.
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Results
A total of 3523 charts and 1802 new prescriptions were
reviewed. Prescribing errors were present in 9.7% of new
prescriptions. Errors in historical data were found in 4%
of the charts reviewed. Incomplete prescriptions and
errors in dosing were the most prevalent error types. The
most common error subcategory was missing instructions,
followed by doses exceeding the recommended dosages.
Figure 1 shows the types of errors detected.
The most common reason for an incomplete prescrip-
tion was missing instructions, followed by a quantity
determination of quantity sufficient without providing a
day’s supply. Anti-infectives accounted for 55% of the
prescribing errors. Figure 2 summarizes the types of med-
ications involved in prescribing errors. Table 1 provides
an overall summary of the types of errors detected. There
was no significant difference in the percentage of pre-
scriptions containing errors for prescriptions written in
February, March, and April.
Discussion
This study shows that errors in prescribing occurred in
almost 10% of new prescriptions written for children pre-
senting at an acute care clinic. More specifically, errors in
Condren et al 51
Figure 2.  Medications involved in prescribing errors.
dosing occurred in 6% of prescriptions written, often exceed-
ing the recommended dose. Many of the errors caused by
incomplete prescriptions did not place the patient in any
immediate danger but would be expected to delay receipt
of the medication, and therefore treatment, by the patient
while the pharmacy awaited clarification of the order.
Because of the study design, it is unknown if the errors that
occurred resulted in untoward clinical outcomes.
There is little data reported describing prescribing
errors for outpatient pediatrics. In a study of pharmacy
data from health maintenance organizations, dosing errors
were evaluated and found to occur in 15% of the prescrip-
tions dispensed for children.2 Although this is higher than
our reported rate of 6%, the prior study only evaluated
overdose errors for specific medications, thus, limiting the
types of prescriptions evaluated. In a study of prescribing
and administration errors for oral outpatient chemother-
apy for children, prescribing errors were only found in 3%
of the prescriptions written.6 This population of patients
received a limited number of medications compared with
our study population.
Studies including a review of prescriptions written for
children in the emergency department (ED) report higher
rates of prescribing errors overall. A study evaluating
errors in a rural ED reported that 39% of prescriptions
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contained an error, but this study included medication
administration errors by the ED staff.7 Only 14% of the
orders contained an error, similar to the current study.
A second study involving a pediatric ED found that 59%
of the prescriptions written by residents contained an
error, with omitted information being the most common
error.8 The majority of the reported errors in this study
arose from failure to include a number of refills on the
prescription. Dosing errors were detected in 6% of pre-
scriptions, results that parallel the current study. A third
study was performed to determine if making changes to a
physician order entry system would decrease errors.9 That
study reported an error rate of 31 per 100 orders before
system modifications and 14 per 100 orders after deploy-
ment of the system changes.
Studies have commented on the role of computerized
order entry in contributing to medication errors. A study of
pediatric inpatient orders showed that 19% of errors could
be attributed to computer use. It identified the computer-
related errors as duplicate orders, selecting the wrong
medication out of a drop-down menu, errors in keypad
entry, and using an inappropriate order set for the patient.10
A second study of inpatient orders for adults reported
that 22 sources of medication errors were facilitated by
computerized physician order entry.11
52 Clinical Pediatrics 49(1)
Table 1.  Summary of Errors Detected
Total (Percentage
Type of Error of Total Errors)
Incomplete/inadequate RX 138 (43)
Directions missing 59 (18.4)
Quantity sufficient (QS) 39 (12)
  with no days supply
Directions unclear 14 (4.4)
Strength missing 10 (3)
Quantity calculated in error 9 (2.8)
Quantity missing 4 (1.3)
Frequency missing 3 (1)
Dosing outside recommended 112 (35)
Exceeds recommended dose 49 (15.3)
Below recommended dose 32 (10)
Frequency outside recommended 15 (4.7)
Outside range for indication 11 (3.4)
Duration outside recommended 5 (1.6)
Drug selection errors 45 (14)
Wrong dosage form 16 (5)
Direction/dosage form mismatch 12 (3.7)
Dosage form not available 9 (2.8)
Not recommended for age 5 (1.6)
Patient allergic to medication 2 (0.6)
Wrong drug selected from list 1 (0.3)
Documentation error 22 (6.9)
Patient taking but not in medication list 15 (4.7)
Wrong weight 4 (1.25)
Allergy not documented 3 (1)
Administration error 4 (1.25)
Technique not recommended 3 (1)
Immeasurable dose 1 (0.3)
This study prompted our institution to investigate
reasons for errors. We identified not only human errors
in math and reference use but also errors with the EMR
system used by the providers. The clinic’s EMR system
has no decision support to prevent ordering inappropriate
dosages of medications. There is no forced completion of
fields, allowing the quantity, frequency, and instruction
fields to remain blank. We discovered errors in calcula-
tions made by the internal dosing calculator leading to
overdose errors. The data also identified EMR training
for providers that would be needed to decrease medica-
tion errors.
In response to this study, multiple efforts have been
undertaken to improve the system, the providers’ use of
the system, and the overall ability to write prescriptions.
Through conducting the study, we have been able to iden-
tify medications that are commonly problematic in order
to increase awareness of the need to double-check pre-
scriptions for these medications. A system remains in
place by which the pharmacist and pharmacy students
check resident, medical student, and high-alert prescrip-
tions and provide feedback to providers when errors occur.
Provider education on how to use the system has been
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incorporated into resident training and monthly clinic ori-
entation. Modifications to the EMR application have been
made to provide dosing guidance for certain medications
and to limit the number of medications and dosage forms
that can be selected for patients. The dosing calculator
errors have been corrected by the EMR vendor.
A limitation of this study is that it did not count the total
number of prescriptions written for specific medications
to determine the frequency with which errors occurred for
an individual product. Therefore, it is possible that the
prescription errors occurred most often for anti-infectives
because they composed the majority of prescriptions writ-
ten. This study did not sort error frequency by provider
type or by patient demographics. Such data would be
helpful for further improving educational programs or
targeting medication review efforts.
One problem encountered when attempting to resolve
errors was that some families could not be reached to
discuss needed changes to the prescriptions. A thorough
prescription review before the prescription leaves the clinic
would increase patient safety by ensuring that an improper
medication or dosage would not reach the patient.
Although the EMR system has brought many advan-
tages to the management of medications, the study has
highlighted some high-level deficiencies of the system.
Our EMR vendor purchases its medication content from a
third-party company, a common practice for EMR sys-
tems. This relationship has handicapped the EMR system’s
ability to rapidly evolve to meet the medication manage-
ment needs of outpatient clinics. Simple changes such as
the ability to highlight the difference between an oral solu-
tion and an intravenous solution have not been
implemented. As this study illustrates, errors in prescrib-
ing can and do happen as a result.
Conclusions
Prescribing errors are common in an academic pediatric
clinic using EMRs. Incomplete prescriptions and dosing
errors were the most commonly identified errors. Identify-
ing the types, frequency, and cause of errors is beneficial
for developing focused educational programs intended to
decrease prescribing errors. This information also increased
the awareness that improvements to EMR systems and
their use need to be explored.
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Condren et al 53

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