A Modified Delphi to Define Drug Dosing Errors in Pediatric Critical Care

Background There is no globally accepted definition for dosing error in adult or pediatric practice. The definition of pediatric dosing error varies greatly in the literature . The objective of this study was to develop a framework, informed by a set of principles, for a clinician-based definition of drug dosing errors in critically ill children, and to identify the range that practitioners agree is a dosing error for different drug classes and clinical scenarios. Methods We conducted a nationwide three staged modified Delphi from May to December 2019. Expert clinicians included Canadian pediatric intensive care unit (PICU) physicians, pharmacists and nurses, with a least 5 years’ experience.Outcomes were dosing principles and error thresholds, as defined by proportion above and below reference range, for common PICU medications and clinical scenarios. Results Forty-four participants met eligibility, and response rates were 95, 86 and 84% for all three rounds respectively. Consensus was achieved for 13 of 15 principles, and 23 of 30 error thresholds. An over-dosed drug that is intercepted, an under-dose of a possibly life-saving medication, dosing 50% above or below target range and not adjusting for a drug interaction were agreed principles of dosing error. Expert clinicians agreed, for most medication categories and clinical scenarios, that dosing over or below 10% of reference range was considered an error threshold. Conclusion Expert clinicians in the PICU agree that, for most intermittent medications and clinical scenarios, dosing over 10% below or above reference range is considered a dosing error.The threshold may be larger for non-toxic medications, and narrower for very toxic medications. This consensus driven definition will help guide routine clinical dosing practice, standardized reporting and drug quality improvement in pediatric critical care.