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BARBARA INSLEY CROUCH, PHARMD., M.S.P.H., is Director, Utah Poison Control Center (UPCC), Salt Lake City; and Professor (Clinical) and Vice-Chair, Department of Pharmacotherapy, College of Pharmacy, University of Utah (UU), Salt Lake City. E. MARTIN CARAVATI, M.D., M.P.H., is Professor, Division of Emergency Medicine, Department of Surgery, and Medical Director, UPCC. ED MOLTZ, B.S.N., CSPI, is Certified Specialist in Poison Information, UPCC, Department of Pharmacotherapy, College of Pharmacy, UU.

Address correspondence to Dr. Crouch at the Department of Pharmacotherapy, College of Pharmacy, University of Utah, 585 Komas Drive, Suite 200, Salt Lake City, UT 84108 (barbara.crouch{at}hsc.utah.edu).

Purpose. Tenfold dosing medication errors reported to U.S. poison control centers in children younger than six years of age were evaluated. Methods. A retrospective review of all exposures in children younger than six years of age reported to the American Association of Poison Control Centers’ data collection system during 2000–04 was conducted. Cases were selected for inclusion if the exposure was an unintentional therapeutic error and if 10-fold dosing error was coded as one of the therapeutic-error scenarios. The specific substance or drug category, patient age and sex, site of exposure, clinical effects, disposition, and outcome were evaluated Results. A total of 3894 10-fold dosing errors involving a single substance in children younger than six years of age were reported over a five-year period. The site of exposure was most commonly a residence (n = 3609, 92.7%), followed by a health care facility (n = 223, 5.7%) and a school (n = 32, 0.8%). More than half of the exposures occurred in children 12 months of age or younger. When stratified by age, histamine H2- receptor antagonists and metoclopramide were the most common medications involved in exposures in children 12 months of age and younger. Cough and cold preparations and antibiotics were the most commonly involved medications in therapeutic errors in children over age 12 months. Conclusion. The most common substances involved in 10-fold medication errors reported to U.S. poison control centers were histamine H2-receptor antagonists and metoclopramide. Most exposures occurred in the home and involved children 12 months of age or younger. Index terms: Data collection; Dosage; Errors, medication; Gastrointestinal drugs; Metoclopramide; Pediatrics; Poison control centers; Poisoning