Five thousand ten pediatric prescriptions were filled at the
Arcade Pharmacy between July and December 2013; 1448 (29%)
pediatric prescriptions were sent to the problem queue; 156
(3%) required pharmacist intervention because of the dosing
procedure; 78 (50%) of those prescriptions were changed
because of the pharmacist intervention. The majority of prescribing
errors resulting in pharmacist intervention were for
dose too high (59%) followed by incomplete, illegible (22%), or
inappropriate dosing interval (14%), and dose too low (5%).
There were 14 (9%) prescriptions for ISMP high-alert
medications that required pharmacist intervention. Among
these prescriptions, 8 (57%) prescriptions were opioids, 4 immunosuppressants
(29%), 1 (7%) hypoglycemic agent, and 1
(7%) chemotherapy. Approximately 30% of patients with prescription
errors weighed less than 10 kg (Fig. 1). More than 50%
of prescribing errors occurred in children younger than 6 years
(Fig. 2). The majority of prescribers were house staff physicians
(67%). The majority of prescriptions requiring intervention
were hand written (77%).