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Division of Clinical
Pharmacology/ Toxicology, Department of Paediatrics and Research
Institute, The Hospital for Sick Children, 555 University Avenue,
Toronto, Ontario M5G 1X8, Canada
Correspondence to: Dr G Koren.
Accepted 3
February 1998
BACKGROUND
Errors in
calculating drug doses in infants and small children can cause
morbidity and mortality, especially with agents exhibiting a narrow
therapeutic window. A previous study from this institution has detected
potential life threatening errors in calculations performed by trainees
while writing prescriptions.
OBJECTIVESTo verify
whether the true incidence of trainees' errors in prescribing can be
explained by impaired calculation skills in written tests.
SETTINGA tertiary
paediatric hospital; educational rounds for core paediatric residents.
METHODSTwo anonymous
written tests, which included calculations of doses similar to those
performed at the paediatric bedside; one was conducted in 1993 and one
in 1995.
RESULTSThirty four
paediatric residents participated in 1993 and 30 in 1995. A substantial
number of trainees in both years committed at least one error. In
general, there was no correlation between the length of training (0 to
4 years) and likelihood of making a mistake. Three trainees in 1993 and
four in 1995 committed 10-fold errors. These seven residents committed
significantly more errors than the rest of the group in each of the
tests separately. All seven were in their first two years of training,
and six were in their first year of residency.
CONCLUSIONSA
substantial proportion of paediatric trainees make mistakes while
calculating drug doses under optimal test conditions. Some trainees
commit 10-fold errors, which may be life threatening. The results of
these anonymous tests suggest that testing of calculation skills should
be mandatory, and appropriate remedial steps should follow to prevent
paediatric patients receiving wrong drug dosages.
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