Compared with adults, children have significant pharmacokinetic
and pharmacodynamic differences, making them
more susceptible to medication errors.4 Previous studies have
shown that the majority of adverse drug reactions and medication
errors occur at the time of physician prescribing, as 74%
of medication errors and 79% of adverse drug reactions
occurred at the stage of physician ordering, and that the most
frequent type of medication error was a dosing error.5,6
Although there are processes for limiting these initial dosing
errors for the inpatient prescriptions, there are limited studies
on medication errors and effective strategies for reducing patient harm in pediatric outpatient care.7 In an attempt to
reduce dosing errors among pediatric outpatient prescriptions,
in 2003, the Johns Hopkins Outpatient Pharmacies implemented
a pharmacist-initiated, weight-based dose checking
procedure for every pediatric (