10x overdose preparation errors for pt specific pediatric doses

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Thu, 05/14/2026 - 11:34
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Lindsey M Eick
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Joined: 07/12/2018 - 14:13
10x overdose preparation errors for pt specific pediatric doses

Hi Everyone
Our pharmacy services both our adult and pediatric hospital patients. We see preparation errors with small volumes (typically less than 0.1-0.2 mL), where a 10 fold dose is drawn up (i.e. 0.9 ml drawn up instead of 0.09 mL). This makes it through pharmacist check and to the floor and is caught by nursing prior to administration. We have seen this occur in both our sterile and non-sterile prep areas and it has occurred throughout the years. There are a lot of factors as to how these errors get through (busy drawing up/checking a lot of doses, volume drawn up is a 'normal' dose for other patients, distractions etc).

Has anyone else experienced these types of errors and successfully implemented any system changes? Would love to hear thoughts on possible solutions.

Thanks!
Lindsey

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