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Table 3 Main drugs related to the most frequent medication errors in the pediatric critical care services (PCCS)

From: A study of medication errors during the prescription stage in the pediatric critical care services of a secondary-tertiary level public hospital

PCCS Types of Medication Errors n (%) Drug related in MEs, n Clinical Relevance or Possible clinical implication*
Mild Severe
PEC Wrong speed rate of administration 45 (11.7) Omeprazole, 40 Abdominal pain, Nausea Respiratory system reactions
Ampicillin, 2 Phlebitis, Injection site pain Morbilliform rash or Serious allergic reactions
Metoclopramide, 1 Diarrhea Acute dystonic reaction
Amikacin, 1 Injection site pain Hearing loss
Ceftriaxone, 1 Rash, Injection site pain Hematological disorders
Abbreviations 258 (67.2) Glucose solution, 98 Phlebitis Hyperosmolar syndrome
Potassium chloride, 53 Injection site pain, Phlebitis Cardiac arrhythmias
Saline solution, 28 Phlebitis Hypervolemia
Phenytoin, 12 Injection site pain, Rash Cardiac rhythm disturbances
Others, 67  
Total No. of MEs 384  
PICU Wrong speed rate of administration 102 (15.8) Omeprazole, 59 Abdominal pain, Nausea Respiratory system reactions
Metoclopramide, 43 Diarrhea Acute dystonic reaction
Spelling error 63 (9.8) Fentanyl, 38 Headache, Nausea, Vomiting Loss of consciousness & Tachycardia
Sufentanil, 15 Headache, Nausea, Vomiting Loss of consciousness & Tachycardia
Furosemide, 8 Electrolyte disorder Cardiac rhythm disturbances
Others, 2  
Misinterpretation/mistaken drug units 46 (7.2) Nystatin, 17 Oral irritation, Sensitization Stevens-Johnson syndrome
Albuterol, 15 Throat irritation, Nausea Cardiac rhythm disturbances
Ipratropium bromide / Albuterol, 12 Throat irritation, Nausea Cardiac rhythm disturbances
Epinephrine, 2 Dizziness, Sweating Cardiac rhythm disturbances
Abbreviations 432 (67.2) Glucose solution, 174 Phlebitis Hyperosmolar syndrome
Potassium chloride, 25 Injection site pain, Phlebitis Cardiac arrhythmias
Saline solution, 66 Phlebitis Hypervolemia
Phenytoin, 17 Injection site pain, Rash Cardiac rhythm disturbances
Others, 150  
Total of ME 643  
NICU Wrong speed rate of administration 31 (22) Omeprazole, 30 Abdominal pain, Nausea Respiratory system reactions
Metoclopramide, 1 Diarrhea, Hypotension Acute dystonic reaction
Spelling error 25 (17.7) Fentanyl, 21 Headache, Nausea, Vomiting Loss of consciousness & Tachycardia
Furosemide, 2 Electrolyte disorder Cardiac rhythm disturbances
Others, 2  
Abbreviations 85 (60.3) Glucose solution, 55 Phlebitis Hyperosmolar syndrome
Saline solution, 9 Phlebitis Hypervolemia
Multivitamin, 4 Stomach discomfort Hypervitaminosis
Others, 17  
Total No. of MEs 141  
NIMCU Wrong speed rate of administration 14 (12.7) Omeprazole, 12 Abdominal pain, Nausea Respiratory system reactions
Vancomycin, 1 Nausea Hypokalemia & Red man Syndrome
Amikacin, 1 Injection site pain Hearing loss
Spelling error 13 (11.8) Fentanyl, 6 Headache, Nausea, Vomiting Loss of consciousness & Tachycardia
Furosemide, 3 Electrolyte disorder Cardiac rhythm disturbances
Others, 4  
Abbreviations 83 (75.5) Glucose solution, 37 Phlebitis Hyperosmolar syndrome
Potassium chloride, 5 Injection site pain, Phlebitis Cardiac arrhythmias
Saline solution, 9 Phlebitis Hypervolemia
Multivitamin, 4 Stomach discomfort Hypervitaminosis
Others, 28  
Total No. of MEs 110  
  1. *The clinical implications were consulted at https://www.drugs.com/sfx/ [25]
  2. HPMC Hydroxypropyl methylcellulose, ME Medication Error, NICU Neonatal Intensive Care Unit, NIMCU Neonatal Intermediate Special Care Unit, PCCS Pediatric critical care services, PEC Pediatric Emergency Care, PICU Pediatric Intensive Care Unit