To the Editor.—

I read with interest the article by Koren et al, "Tenfold Errors in Administration of Drug Doses: A Neglected Iatrogenic Disease in Pediatrics" (Pediatrics 1986;77:848-849). Errors such as those described by the author are perhaps most likely to occur during an emergency resuscitation situation. Several factors contribute to this increased likelihood. (1) emotional stress of the situation, (2) the urgency of need for the medications, leading to excessive haste in their preparation for administration and at the same time a decrease in the likelihood that the dose will be double checked before administration, and (3) the relative lack of familiarity of the members of the resuscitating team with the medications being used.

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