Antipsychiatric Medication Errors in Children Boarded in a Pediatric Emergency Department

Usha Sethuraman, Nirupama Kannikeswaran, Ahmad Farooqi, Kimone Richards, James Chamberlain

Research output: Contribution to journalArticlepeer-review


OBJECTIVES: Mental health visits to the pediatric emergency department (PED) have increased significantly. Our objective was to describe medication errors in children with mental health illness who were boarded in a PED for more than 6 hours. METHODS: We conducted a retrospective study from 2014 to 2015 of children 6 to 18 years with psychiatric complaints and a length of stay of more than 6 hours. Admitted patients and those not on home medications were excluded. We collected demographics, number, types, and doses of antipsychiatric medications and errors. RESULTS: A total of 676 patients (53.1% males) with a median age of 14 (interquartile range, 12, 15) years were included. The median length of stay was 11.7 (interquartile range, 8.5, 20.5) hours. A total of 974 medication errors occurred in 491 (72.7%) patients. Omission errors were noted in 376 patients (76.6%), commission in 44 patients (9.0%), and both in 71 patients (14.4%). Among commission errors, 8 (18.1%) were serious and 8 (18.1%) were significant. One third of patients (30.5%) had 1 medication error, 23.9% had 2, 11.7% had 3, and 5% had 4.Medication errors were most commonly noted in antidepressant and antipsychotic classes. One third (35.8%) of errors involved 2 medication classes. Being on 3 (odds ratio, 1.8; 95% confidence interval, 1.09-2.9) or 4 or more (odds ratio, 2.81; 95% confidence interval, 1.54-5.34) antipsychiatric medications was significantly associated with a prescription error. CONCLUSION: There is a high incidence of medication errors, particularly those of omission, among antipsychiatric prescriptions in children boarded in the PED. A refinement of current medication reconciliation and integration of psychiatric medication databases between the PED and pharmacies are urgently needed to reduce these errors.

Original languageEnglish
Pages (from-to)e538-e542
JournalPediatric Emergency Care
Issue number9
StatePublished - Sep 1 2021
Externally publishedYes


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