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To the Editor: Dr Kaushal and colleagues¹ reported that more than 93% of the medication errors they identified in children might have been prevented by computerized physician order entry (CPOE) and ward-based clinical pharmacists. The problem of medication errors in pediatric inpatients has been known for some time. We reported the value of clinical pharmacist involvement in preventing medication errors in children's hospitals in 1987.²

Clinical pharmacists in children's hospitals deal daily with the special medication needs of pediatric and neonatal patients, whose weights can vary from 400 g to 120 kg. Because the dosing of most drugs is based on weight, there is the potential for a 300-fold dosing error. In adult patients, a 2-fold dosing error is usually the maximum encountered, as pharmaceutical manufacturers provide medications in adult unit dose packaging. Few drugs are available from manufacturers in ready-to-administer pediatric or neonatal unit doses or dosage forms. Pediatric . . . [Full Text of this Article]

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