Background Extemporaneously compounded medicines are widely used in paediatric patients. However, the associated extent and nature of adverse drug events from these products remained unclear. Aims To summarise the characteristics of adverse drug events reported from the use of compounded medicines in children and determine the types of adverse drug events, medications most frequently involved, and reasons for medication errors. Methods A search was performed in Medline via Ovid, CINAHL, Embase, Scopus and the ISMP Canada Safety Bulletins to identify studies that described adverse drug events associated with community pharmacy compounded medicines. There were no restrictions based on country or publication date. Two authors independently screened titles, abstracts and full texts of studies of the studies found and extracted data with a standardised extraction table. Information extracted included study characteristics, details regarding the compounded medicine and clinical characteristics. Results We identified 37 cases across 25 studies. There were 31 cases of compounding errors, 5 cases of administration errors and 1 case of dispensing error. The most common compounding error types were incorrect concentration in the formulation, substitution or addition of an active ingredient that was not prescribed. The most commonly reported medicines were clonidine (n=7) and flecainide (n=5). The median age of children involved was 2 years (IQR 0.9–5.5 years). Two deaths were reported, following exposures to baclofen and tacrolimus. Conclusions This review highlights the importance of thoroughly verifying active ingredients and their concentrations when compounding paediatric formulations in community pharmacies.
Li et al. (Thu,) studied this question.