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Medication Errors in Paediatrics

A Case Report and Systematic Review of Risk Factors

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Table I

References

  1. Ptachcinnski RJ, Burckart GJ, Venkataraman R. Cyclosporin. Drug Intell Clin Pharm 1985; 19: 90–100

    Google Scholar 

  2. Min DI, Monaco AP. The complications associated with transplant immunosuppression and their management. Pharmacotherapy 1991; 11: 119–25S

    Google Scholar 

  3. Rush DN. Cyclosporine toxicity to organs other than the kidney. Clin Biochem 1991; 24: 101–5

    Article  PubMed  CAS  Google Scholar 

  4. DeGroen PC, Aksamait AJ, Rakela J, et al. Central nervous system toxicity after liver transplantation. N Engl J Med 1987; 317: 861–6

    Article  CAS  Google Scholar 

  5. Baumhefner RW, Myers LW, Ellison GW, et al. Huge cyclosporin overdose with favourable outcome. Lancet 1987; II: 332

    Article  Google Scholar 

  6. Honcharik N, Anthone S. Activated charcoal in acute cyclosporin overdose [letter]. Lancet 1985, I: 1051

    Article  Google Scholar 

  7. Schroeder TJ, Wadhwa NK, Pesce AJ, et al. An acute overdose of cyclosporine. Transplantation 1986; 41: 406–9

    Article  PubMed  CAS  Google Scholar 

  8. Wallemacq PE, Lesne ML. Accidental massive IV administration of cyclosporin in man. Drug Intell Clin Pharm 1985; 19: 29–30

    PubMed  CAS  Google Scholar 

  9. Kokado Y, Takahara S, Ishibashi M, et al. An acute overdose of cyclosporine. Transplantation 1989; 47: 1096–7

    Article  PubMed  CAS  Google Scholar 

  10. Leblaye I, Donatini B, Krupp P. Acute overdosage with sandimmun: the influence of dose and patients’ underlying condition. Nephrol Dial Transplant 1994; 9: 219–20

    CAS  Google Scholar 

  11. Sketris IS, Onorato L, Yatscoff RW, et al. Eight days of cyclosporine overdose: a case report. Pharmacotherapy 1993; 13: 658–60

    PubMed  CAS  Google Scholar 

  12. De Meer K, Houwen RHJ, Bijleveld CMA, et al. Blood concentrations after accidental cyclosporin overdose. Eur J Pediatr 1989; 149: 219–20

    Article  PubMed  Google Scholar 

  13. Anderson AB, Primack W. Treatment of a child with acute cyclosporine overdose [letter]. Pediatr Nephrol 1992; 6: 222

    Article  PubMed  CAS  Google Scholar 

  14. Arellano F, Monka C, Krupp PF. Acute cyclosporin overdose: a review of present clinical experience. Drug Saf 1991; 6: 266–76

    Article  PubMed  CAS  Google Scholar 

  15. Koren G, Haslam RH. Pediatric medication errors: predicting and preventing tenfold disasters. J Clin Pharm 1994; 34: 1043–5

    CAS  Google Scholar 

  16. Hoffman JP. More on ‘Losec or Lasix?’ [letter]. N Engl J Med 1990; 323: 1428

    PubMed  CAS  Google Scholar 

  17. Costable Jr JM, McKinley MJ. Prozac or prilosec for gastric ulcer [letter]? N Engl J Med 1996; 335: 600

    Article  PubMed  Google Scholar 

  18. Baily B, Einarson A, Koren G. Alert over sound-alike drugs. Can Med Assoc J 1997; 157: 16–8

    Google Scholar 

  19. Burt RAP. Prescribing precisely: a need for nominal accuracy. Proc R Physicians Edinb 1997; 27: 543–6

    Google Scholar 

  20. Koren G, Soldin S, MacLeod SM. Organization and efficacy of a therapeutic drug monitoring consultation service in a pediatric hospital. Ther Drug Monit 1985; 7: 295–8

    Article  PubMed  CAS  Google Scholar 

  21. Perlstein PH, Callison C, White M, et al. Errors in drug computations during newborn intensive care. Am J Dis Child 1979; 133: 376–9

    PubMed  CAS  Google Scholar 

  22. Koren G, Brazilay Z, Greenwald M. Tenfold errors in administration of drug dosage: a neglected iatrogenic disease in pediatrics. Pediatrics 1986; 77: 848–9

    PubMed  CAS  Google Scholar 

  23. Koren G, Barzilay Z, Modan M. Errors in computing drug doses. Can Med Assoc J 1983; 129: 721–3

    PubMed  CAS  Google Scholar 

  24. Rieder MJ, Goldstein D, Zinman H, et al. Tenfold errors in drug dosage. Can Med Assoc J 1988; 139: 12–3

    CAS  Google Scholar 

  25. Yee GC, Lennon TP, Gmur DJ, et al. Age-dependent cyclosporine: pharmacokinetics in marrow transplant recipients. Clin Pharmacol Ther 1986; 40: 438–43

    Article  PubMed  CAS  Google Scholar 

  26. Wandstrat TL, Schroeder TJ, Myre SA. Cyclosporine pharmacokinetics in pediatric transplant recipients. Ther Drug Monit 1989; 11: 493–6

    Article  PubMed  CAS  Google Scholar 

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Acknowledgements

This work was supported by a grant from The Medical Research Council of Canada.

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Correspondence to Gideon Koren.

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Diav-Citrin, O., Ratnapalan, S., Grouhi, M. et al. Medication Errors in Paediatrics. Paediatr Drugs 2, 239–242 (2000). https://doi.org/10.2165/00128072-200002030-00007

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