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Reducing ADHD Medication Errors for Children at Home and in the Community

September 20, 2023

Editor’s Note: Beth Dworetzky's son was born with a complex heart condition. She and her son navigated a fragmented health care system for 31 years until his death in October 2021. -Cara L. Coleman, JD, MPH, Associate Editor, Pediatrics

Family Connections with Pediatrics

Neurodevelopmental disorders affect how a child’s brain grows and develops, and impact how a child learns, behaves, handles emotions, and more. The most common neurodevelopmental disorder in children is attention deficit/hyperactivity disorder (ADHD). About 3.3 million US youth younger than 20-years of age take ADHD medication. Examples of ADHD medications include amphetamines, such as Adderall, and methylphenidates, such as Ritalin and Concerta. This month’s Pediatrics includes a study that discusses these medications and errors in giving these medications in, ‘Pediatric ADHD Medication Errors Reported to United States Poison Centers, 2000-2021’ (10.1542/peds.2023-061942).

How did the authors study this?

The authors examined ADHD medication errors reported to the National Poison Data Systems from 2000 through 2021. These are errors that occur in the home, at school, and in other community settings where children spend time.

What did the study find?

During the 22 years of data, there were 87,691 ADHD medication errors reported to US Poison Centers. The types of medication errors included:

  • Took someone else’s medication
  • Given the wrong medication
  • Given doses too close together
  • Pharmacist/nurse error
  • Incorrect concentration of medication given, both too much and too little
  • Confused units of measure

The number of errors reported per year was not constant. In some years there were more errors reported than others and from 2019 to 2021, there were fewer medication errors reported. The authors note that this corresponds to a reduction of ADHD medication use during the COVID-19 pandemic when many students attended virtual school.

Other findings included:

  • The highest number of medication errors were for 6- to 12-year-olds
  • Males were more likely to experience medication errors than females
  • Most errors occurred in the home, followed by at school, and other locations
  • Most errors did not result in the child being hospitalized
  • Children younger than 6 were more likely to have a serious medical outcome

What can you do with this article?

  1. Share the article with your child’s doctor as a way to talk about and plan for proper medication use.
  2. Talk with your pharmacist and make sure you understand the concentration of the ADHD medication, and how and when it should be given to your child.
  3. Talk with the school nurse to make sure they understand how your child will take ADHD medication during the school day.
  4. Depending on your child’s age and understanding of their ADHD diagnosis, speak with your child about how to be responsible for taking ADHD medication, to never share medication, or take someone else’s medication.
  5. Work with your child to use charts or weekly pill dispensers to track when medication is taken.
  6. Work with your child to set reminders on your phone or your child’s phone to take medication on time.
  7. Post the number for US Poison Control near your phones, or add it to your cell phone contacts. 1-800-222-1222.
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