Table 1

Potentially fatal prescription errors

DrugPatient characteristicsInitial prescriptionPrescription after recommendation
Tenfold errorsAmiodarone2-year-old child (10 kg)50 mg/kg5 mg/kg
Epinephrine5-month-old infant (8 kg)10 µg/kg/min1 µg/kg/min
Heparin9-month-old infant (9.8 kg)200 IU/kg/h20 IU/kg/h
HeparinExtremely critical 1-year-old child (10.1 kg)100 IU/kg/h10 IU/kg/h
OverdosingDigoxin15-month-old child (10.5 kg)10 µg/kg three times a day5 µg/kg twice daily
Epinephrine3-month-old infant (5.3 kg)12 µg/kg/min0.4 µg/kg/min
EpinephrineExtremely critical 2-year-old child (9.8 kg)10 µg/kg/min3 µg/kg/min
FentanylExtremely critical neonate (1.2 kg)80 µg/kg/h10 µg/kg/h
Gentamicin1-year-old child with extracorporeal renal replacement therapy (9.6 kg)20 mg/kg5 mg/kg
Heparin1-year-old child with extracorporeal renal replacement therapy (10.2 kg)85 IU/kg/h15 IU/kg/h
Insulin2-year-old child (13 kg)1 U/kg/h0.2 U/kg/h
Insulin9-month-old infant (9 kg)15 U/kg/h0.15 U/kg/h
MorphineNeonate (2.7 kg)60 mg (6 ml 1% morphine)0.6 mg
MorphineExtreme low-weight premature infant (0.760 kg)760 mg0.760 mg
Morphine1-year-old child (12.8 kg)20 mg/kg/h20 µg/kg/h
Potassium chloride3-year-old child (16.8 kg)40 mEq/kg/h40 mEq/h
PropofolExtremely critical neonate (1.3 kg)60 mg/kg/h4 mg/kg/h
RemifentanylExtremely critical 8-month-old infant (9.1 kg)4 µg/kg/min1 µg/kg/min
UrapidilExtremely critical 9-month-old infant (10.1 kg)10 mg/kg/h0.8 mg/kg/h
UnderdosesAciclovirNeonate (2.5 kg)1.5 mg/kg20 mg/kg
AmikacinNeonate (1.8 kg)1.5 mg/kg15 mg/kg
AmiodaroneNeonate (1.2 kg)0.5 µg/kg/min5 µg/kg/min
Amiodarone9-month-old infant (8.2 kg)1 µg/kg/min7 µg/kg/min
Dopamine3-year-old child (14.8 kg)0.2 µg/kg/min20 µg/kg/min
InsulinCritical 11-month-old infant (11 kg)0.01 U/kg/h0.1 U/kg/h
Labetalol4-year-old child (18 kg)0.03 mg/kg/h3 mg/kg/h
NaloxoneNeonate (2.1 kg)10 µg/kg100 µg/kg
NaloxoneNeonate (1.5 kg)10 µg/kg100 µg/kg
NitroprussiateNeonate (3.2 kg)0.03 µg/kg/min3 µg/kg/min
OtherMetamizoleCritical 2-year-old child (12.1 kg)Contraindicated in aplastic anaemia patients