Paracetamol dosing errors at two tertiary paediatric hospitals: a retrospective analysis of prescribing and administration errors

Paracetamol is commonly prescribed in paediatric hospitals and frequently associated with medication errors. This study examined the prevalence and factors associated with paracetamol dose errors in prescribing and administration in tertiary paediatric hospitals. We carried out a secondary analysis of data from two paediatric hospitals in Sydney, Australia. Prescribing errors were identified through chart review of 12,304 paracetamol orders across 3 years (2016, 2017 and 2020). Administration errors were assessed through direct observation of 796 doses given by 212 nurses at one hospital in 2016. Multilevel regression models identified factors associated with errors. The prescribing dose error rate was 10.1 per 100 orders, with 88.2% being overdoses. Overdose rates increased with age until 13 years (incidence rate ratio (IRR) 1.13 per year, 95% confidence interval (CI) 1.11–1.15) then decreased (IRR 0.90 per year, 95% CI 0.84–0.96), while underdose rates were highest in infants. Of all dose errors, 64.1% reached patients. Administration observations revealed 6.2% of doses had errors, with higher odds on weekends (OR 3.8, 95% CI 1.6–8.9) and substantial variation between nurses (variance partition coefficient 0.44). Most administration errors were within 25% of prescribed dose, although seven were > 40% above prescribed dose. Paracetamol dosing errors remain common in paediatric hospitals, with distinct age-related patterns suggesting specific challenges in dose calculation. The high rate of errors reaching patients, combined with nurse variation in administration errors, indicates that both prescribing and administration systems need strengthening, particularly regarding weekend staffing and standardisation of medicine preparation practices.