Tenfold errors and other dosing mistakes in paediatric care
Weight-based dosing, liquid formulations and adult-sized products combine to make children unusually vulnerable to medication errors.
In brief
Why children face more medication errors, from tenfold decimal mistakes to mg/mL mix-ups, and the safeguards that work in hospitals and at home.
- Children are more exposed to dosing errors because almost every dose must be calculated.
- A misplaced decimal point can produce a tenfold overdose.
- Standard concentrations, smart pumps and metric-only dosing devices reduce risk.
In adult care, most doses come in fixed strengths: one tablet, one vial. In paediatric care, almost every dose is calculated from the child’s weight, and often measured from a liquid or diluted from an adult-strength product. Each step is a chance for error.
Why children are more exposed
A landmark 2001 study of hospitalised patients found that potentially harmful medication errors were considerably more common in children than in adults, particularly in neonatal intensive care. The reasons have not fundamentally changed:
- Calculation. Doses depend on accurate, up-to-date weights and correct arithmetic.
- Dilution. Adult concentrations often have to be diluted for small children.
- Units. Confusion between milligrams and millilitres, or micrograms and milligrams, is a recurring cause of harm.
- Reserve. Small children have less physiological reserve to tolerate an overdose.
The tenfold error
The signature paediatric mistake is the tenfold error: a misplaced or missing decimal point that turns 0.5 mg into 5 mg. Writing a trailing zero (5.0 mg) or omitting a leading one (.5 mg) are classic causes, and safety bodies have long advised against both.
What works
- Standard concentrations for infusions, so that every unit uses the same strength.
- Smart infusion pumps with drug libraries and dose limits.
- Electronic prescribing with weight-based dose checking.
- Metric-only oral syringes for liquid medicines at home, replacing teaspoons and cups.
- Independent double checks for high-risk medicines.
The manufacturer’s role
Many errors begin with products that were never designed for children. Paediatric strengths, clear labelling of concentration and dosing devices that match the label are design decisions, and they belong in a paediatric development plan alongside the clinical studies.
