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Children in hospitals are prescribed dramatic and dangerous overdoses of medication more often than people think, a new Canadian report says.

Earlier studies have shown that children face a greater risk than adults of receiving the wrong dose of medication. But researchers at the Hospital for Sick Children now suggest that those errors tend to be large: that a dose 10 times or one-tenth the right one may be given.

"These were major errors," said Gideon Koren, professor of pharmacology at the University of Toronto and a senior scientist at the Hospital for Sick Children. "They were errors that could be harmful or even fatal if not intercepted."

Medical mistakes, specifically those involving drugs, are estimated to kill as many as 10,000 Canadians a year. Studies like these suggest that many of those deaths could be children.

"The public, the parents, should not expect errors and we have to have medical systems that prevent them," Dr. Koren said.

The study, published in today's New England Journal of Medicine, found that from April to November of 2000 there were reports of 20 errors at the hospital involving 19 medications in which the dosages were wrong by a factor of 10.

Most were potent drugs. In six of the 20 cases, they were potentially deadly; in nine others, seriously toxic.

The mistakes were caught in 15 of the 20 cases before the incorrect dose was administered. But five children, including one newborn, did receive the wrong prescription.

While these resulted in no long-term harm, Dr. Koren said, "It is no consolation for us; an error is an error."

The findings appear to raise questions about dosing practices at one of the country's leading pediatric centres, but Dr. Koren said the problem is widespread and likely is more pervasive at institutions that do not have systems to track medications.

"Sick Kids is the best place for a child to be because we have the systems in place to catch the mistakes," he said.

The study, for example, found that relying on "spontaneous reports of large dosing errors may underestimate the true incidence."

A Harvard Medical School study published last year found that medication errors in treating children in hospital are relatively common.

It concluded that children are three times as likely as adults to get the wrong dose of a drug. Most vulnerable are the youngest and sickest, because their small size means doctors must estimate the appropriate dose. Most drugs are tested only on adults before they reach the market, in part because experimenting on children raises tricky questions of ethics.

As a result, doctors have to rely on a combination of "science and art" to calculate a proper dose for a child. "And size," Dr. Koren said, "is not the only factor in a complex equation where children's bodies, and certain organs, like the kidneys, can develop at different rates."

Doctors were responsible for 18 of the 20 mistakes in the study.

Yet Dr. Koren believes, as did the Harvard group, that errors with children's medication could be significantly reduced if hospitals had a computerized prescription tracking system and a policy of reporting errors.

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