Medication errors occur in the pediatric population in both the
inpatient and outpatient settings. Pediatric medication errors
occur at a rate of about 16% of cases.1 Listing all the
potential medication errors is impossible. In this series, I
focus on 10 errors commonly seen in the pediatric outpatient
setting. In previous articles, I described common errors
associated with infant acetaminophen,2 insulin,3 and
ceftriaxone(Drug information on ceftriaxone).4 A 3-year-old boy
(weight, 17 kg) with a history of eczema presented to the clinic
with severe pruritus. No topical remedies seemed to help. The
clinician wrote a prescription for hydralazine(Drug information
on hydralazine) at 8 mg PO q6h PRN (about 2 mg/kg/d). After the
prescription was picked up from the pharmacy, the patient needed
to take the medication around the clock to alleviate the
symptoms. The patient was seen at the clinic again the next day
because of increased lethargy and confusion. His vital signs
were obtained, and he was found to be hypot