Study: ADHD medication errors increase nearly 300%
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Key takeaways:
- Researchers uncovered 87,691 cases of ADHD medication errors over 21 years.
- Children younger than 6 were twice as likely to experience a serious medical outcome following an error as those aged 6 to 19.
ADHD-related medication errors increased almost 300% from 2000 to 2021 among people aged younger than 20 years, a study found.
ADHD is among the most common pediatric neurodevelopmental disorders, and evidence indicates that prescriptions for ADHD medications jumped during the COVID-19 pandemic.
“Approximately 3.3 million children — or roughly five out of every 100 children in the U.S. — are currently prescribed medication for ADHD,” Gary Smith, MD, DrPH, director of the Center for Injury Research and Policy at Nationwide Children’s Hospital in Columbus, Ohio, told Healio.
“This study investigated the characteristics and trends of out-of-hospital ADHD medication errors among people younger than 20 years old reported to U.S. poison centers from 2000 through 2021,” he said.
Smith and colleagues examined data from 2000 to 2021 using the National Poison Data System, which is maintained by America’s Poison Centers and includes information from calls made to U.S. poison centers. They specifically focused on exposures designated “unintentional therapeutic errors” involving ADHD medications.
During the study period, there were 87,691 cases in which ADHD medications were listed as first-ranked exposures — those judged to be the most likely cause of a patient’s clinical symptoms. The 6- to 12-year age group accounted for 67% of these errors, but children aged younger than 6 years were twice as likely to experience a serious medical outcome following a medication error, and were over three times as likely to be admitted to a health care facility than children aged 6 to 19 years. The more common scenarios included a child inadvertently taking or being given medication twice (54%), a child inadvertently taking or being given someone else’s medication (13%) and a child being given or taking the wrong medication (13%).
During the study period, there were 124,383 total ADHD medication errors, with an overall increase of 299%.
Smith told Healio that he “would not characterize any of the study findings as surprising.”
“The increase in ADHD medication errors parallels the increase in ADHD diagnoses,” Smith said. “We are unaware of data showing that health care providers became more likely to prescribe medications to a child with the diagnosis of ADHD during the past 2 decades. Therefore, we are unable to comment on whether changes in prescribing practices may have contributed to the observed increase in ADHD medication errors.”
Because therapeutic errors are preventable, more attention should be given to patient and caregiver education and development of improved child-resistant medication dispensing and tracking systems, Smith said.
“Primary care providers and pediatricians should continue to provide clear instructions to patients and child caregivers about dosing and timing of medications,” Smith said. “They may wish to consider using teach-back and other techniques to ensure understanding.”
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